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Emergency Management of
Seizures
Deb Funk, M.D., NREMT-P
Medical Director;
Albany MedFLIGHT
Saratoga EMS
Goals

Review definitions, classifications and
pathophysiology
 Discuss several patient scenarios
– Assessment
– Management

Discuss current pharmacologic techniques
for management of ongoing seizures
Definitions

Seizure: episodic abnormal neurologic functioning
caused by abnormally excessive activation of
neurons

Epilepsy: a clinical condition characterized by
recurrent seizures

status epilepticus: >30min seizure or >2 seizures
w/o recovery
Epidemiology

6-10% of US population will have at least 1
afebrile seizure during their lifetime
 1-2% have recurrent seizures
 100,000 new cases in US annually
– Adult first time seizures represent 1% of all ED
visits

incidence highest <20 and >60yrs
 Male > female
Classification

primary/secondary
– Primary do not have obvious source
– Secondary occur as a result of many types of
injuries/illnesses

generalized/focal
– generalized involves abnl neuron activity in both
cerebral hemispheres
 tonic/clonic, absence, myoclonic
– focal involve 1 hemisphere
 simple partial, complex partial, secondarily
generalized
Generalized: Tonic-Clonic
Seizure

most common
 vague prodromal symptoms
 tonic phase
– trunk flexion-->extension, eyes deviate up,
mydriasis, vocalization

clonic phase
– tonic contractions alternate with muscle atonia
Generalized: Tonic-Clonic
cont’d

loss of consciousness and autonomic alterations
during both phases
 any focality noted during or after seizure may
point to the origin
 hypocarbia (resp alkalosis/lactic acidosis),
transient hyperglycemia, CSF pleocytosis,
elevated serum prolactin
 post ictal phase
– coma-->confusional state-->lethargy, myalgia,
headache
Pathophysiology of Seizures

in general not well understood
 neuronal recruitment is a common theory and has
been demonstrated in some studies
– propagation of abnormal electrical impulse to adjacent
neurons along variable paths
– the pathway involved usually determines the type of
seizure seen


generalized sz: focus deep and midline, involving the RAS
focal sz: more limited focus of activity/does not cross midline
Pathophysiology cont’d

typically self limited
– bursts of electrical discharges from the focus
terminate

reflex inhibition/neuronal exhaustion/alteration of
neurotransmitter balance.
Case 1


2 yr old previously healthy boy given
Tylenol for tactile temp by Mom. Twenty
min later had “shaking episode.”
What more do you need to know?
 What do you look for on exam?
 What is your assessment and plan?
Febrile Seizure: Definitions

generalized seizure occurring during a sudden rise
in temp in absence of intracranial infection or
other defined etiology
 Simple: single event lasting less than 15 min
(90%)
 Complex: exceed 15 min, occur more than once in
24hr period, or show focal motor manifestations
(higher rate of epilepsy)
Febrile Seizure: Statistics

2-5% of children
 most common pediatric seizure
 30% will have a single recurrence (1/2 of
these will have multiple)
 age of onset 6mos-5yrs (peak 18-24 mos)
 family history conveys 2-3 times the
general population risk
 2-9% develop afebrile seizures
Febrile Seizures: Assessment

History
– PMH/AMPLE (immunization hx)
– Recent illness
– Details of event

Physical Exam
– MS/ABC’s
– Detailed neuro exam
– Search for source of fever (in ED)
Febrile Seizure: management

ABCs and monitor VS
 Check blood glucose
 abort seizure if ongoing (benzodiazepine)
– IV/IM/PR administration

Cooling measures
 Transport to appropriate hospital
Reference REMO Protocol P-10 Pediatric Seizures
Case 2


42 y/o WM reportedly had a seizure at a
Phish concert. Friends think he takes
Dilantin.
What more do you need to know?
 What do you look for on exam?
 What is your assessment and plan?
Epilepsy: Considerations

multiple different epilepsy syndromes
 breakthrough vs noncompliance
 provoking factors
Epilepsy: statistics

Affects 1.5-2.5 million people in US
 30-40% patients with epilepsy continue to
have breakthrough seizures despite
appropriate medical management
Epilepsy: assessment

History
– determine:








intercurrent illness/trauma
Sleep deprivation
drug or etoh use
drug drug interactions
med compliance
recent change in dosing regimen
change in seizure pattern
Physical Exam
– Evidence of injury
– Detailed neuro exam
Epilepsy: management
MS/ABC’s
 Monitor VS and check blood glucose
 Treat any injuries
 Transport to appropriate hospital
 IV and ALS monitor:

– Multiple seizures
– Single seizure without return to baseline state
– Atypical seizure (type or pattern)
Reference REMO Protocols M-2 Active Seizures
Case 3


19 y/o female college student who “fell out”
at a party. Witnesses describe generalized
seizure activity. Confused/combative upon
EMS arrival.
What more do you need to know?
 What do you look for on exam?
 What is your assessment and plan?
Differential Considerations








Syncope
Hyperventilation syndrome
Prolonged breathholdling
toxic and metabolic disorders
– ETOH abuse/withdrawal
– hypoglycemia
other CNS event (TIA, migraine, narcolepsy)
movement disorders (hemiballismus, tics)
Psychiatric disorders (fugue state, panic attacks)
Functional Disorders (pseudoseizure)
Characteristics of Seizure

abrupt onset
 brief duration (90-120 sec)
 Altered mental status (except simple partial)
 purposeless activity
 unprovoked (except febrile)
 postictal state (except simple partial and
absence)
First Time Seizure: Statistics

Rates of recurrence 23-71%
 Predictors of recurrence
– Etiology of seizure
– EEG findings
Historical Information

History vital in determining the appropriate ED approach
–
–
–
–
–
–
description of event
preceding aura
loss of bowel/bladder
duration of event
post ictal period
clinical context (precipitating factors?)
 febrile illness
 head trauma
 sleep deprivation
 other stressor
– baseline seizure pattern
Initial Assessment

No longer seizing: recovery position, IV, glucose,
medication history
– preventative medications?

Is seizing still:
– Airway assessment (npa, suction, ETT prn)
– protect patient from self injury
– pulseox, monitor, IV access, blood glucose

(hypoglycemia is the most common metabolic cause of sz, but
can also be a result of prolonged sz…needs to be treated
aggressively either way)
– abortive therapies
Detailed Physical Exam

Done after cessation of seizure activity
 assess for injuries
– posterior shoulder dislocation common





Temperature assessment
Bedside glucose determination
Cardiac Monitor
Assess for presence of systemic disease, toxic
exposure, infection, focal neurologic event
serial neurologic exams
– Todd’s paralysis: focal deficit following a seizure
lasting less than 48 hours
Typical Physical Exam
Findings

HTN, tachycardia, tachypnea during seizure
activity
 incontinence, vomiting, tongue biting
 low grade temp common after generalized
seizure
First Time Seizure:
Management
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
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MS/ABC’s
Monitor VS and check blood glucose
IV access (draw labs)
Cardiac monitor
Treat any injuries
Transport to appropriate hospital
No benzodiazepines unless seizure recurs or
continues
Reference REMO Protocols M-2 Active Seizures
Case 4
6 y/o WF presents s/p “seizure.” During
transport EMS witnesses a generalized
tonic-clonic event.
 What more do you need to know?
 What do you look for on exam?
 What is your assessment and plan?

Status Epilepticus:
Considerations

continuous clinical or electrical seizure activity or
repetitive seizures with incomplete neurological
recovery for >30 min
 Continuous seizure activity for >10min should be
treated as if in SE (most seizures last 1-2 min)
 impending SE if >3 tonic-clonic seizures within
24hrs
 Generalized or Partial
Status Epilepticus:
Considerations
Generalized convulsive activity results in:

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hypoxia
hyperpyrexia
BP instability and cerebral dysautoregulation
respiratory and metabolic acidosis
hyperazotemia/hypokalemia/hyponatremia
hyperglycemia followed by hypoglycemia
marked elevations of prolactin, glucagon, growth
hormone and corticotropin
rhabdomyolysis may produce myoglobinuria and
renal failure
Status Epilepticus: Statistics

195,000 episodes in US annually
 42,000 deaths annually in US
 50% due to acute CNS insults (anoxia, TBI, CVA,
neoplasm, infection)
– peds: fever/infection
– elderly: cerebrovascular disease

20% in epileptic patients during med adjustment
or due to noncompliance
 30% undetermined etiology
Status Epilepticus:
Assessment

HPI/AMPLE
 Detailed exam and history taking done once
seizure has been stopped and patient has
been stabilized

Status Epilepticus:
Management
Rapid Seizure control
– Patients do better when seizure treated by EMS

Step 1:
– ABC’s


–
–
–
–
NPA, OPA, ETT
If RSI needed use only short acting paralytics
blood glucose
Cardiac Monitor
IV access
HPI/PE

Further specific treatment based upon circumstance
Status Epilepticus:
Management

Step 2: 1st line drugs
 Step 3: 2nd line drugs
 Step 4: 3rd line drugs

The longer the seizure continues;
– The more difficult it is to stop
– The more likely permanent CNS injury will
occur
Medication Options

First line
– diazepam (Valium) IV/ET/IO/PR
– lorazepam (Ativan)IV/IN
– midazolam (Versed)IV/IM/IN

Second line
– phenytoin/fosphenytoin
– phenobarbital

Lastly induction of anesthesia w. cont. EEG
– Infusions of midazolam, diprivan, valproic acid,
pentobarbital
– Inhaled isoflurane
Rectal Route of Administration
• Surface area=200-400 cm2 (1/10,000 absorptive area of small intestine)
• Highly vascularized
• Passive diffusion
Rates of Diazepam Absorption
by Various Routes
Moolenaar F. Int J Pharma. 1980.
First Line Anticonvulsants
DRUG
ADULT DOSE
PEDS DOSE
Diazepam
.2mg/kg up to
20mg at 2mg/min
.2-.5mg/kg IV/IO CNS/CV/Resp
or .5-1.0mg/kg PR depression
up to 20mg
Onset 1min
Lasts 20-30min
(longer PR)
Lorazepam
.1mg/kg IV max
10mg at 2mg/min
**Intranasal use
promising
.05-.1mg/kg IV
.1mg/kg IV up to
10mg at 1mg/min
or .2mg/kg IM
**Intranasal use
promising
.15mg/kg IV
.2mg/kg IM
Midazolam
**Intranasal use
promising
**Intranasal use
promising
OTHER INFO
CNS/CV/Resp
depression
Onset 2min
Lasts >12hrs
Less depression
Onset 1min
Short duration
Second Line Anticonvulsants
DRUG
ADULT DOSE
PEDS DOSE
OTHER INFO
Phenytoin
20mg/kg IV at
50mg/min
20mg/kg IV at
1mg/kg/min
Hypotension,
arrhythmias
Onset 10-30min
Long acting
Fosphenytoin
15-20PE/kg IV
10-20PE/kg IV
Can be given
at 150mg/min or at 3mg/kg/min or faster
20PE/kg IM
20PE/kg IM
Expensive
Same times once
given
Phenobarbital
10-20mg/kg IV
at 30mg/min or
20mg/kg IM
May rpt to
40mg/kg total
Same as adult
Resp/CV
depression
Rapid onset,
long acting
Third Line Anticonvulsants
DRUG
ADULT
PEDS
OTHER
Midazolam
.15mg/kg IVthen As adult
1mcg/kg/min
up 1mcg/kg/min
q15
Propofol
1-3mg/kg IV
then 210mg/kg/h
Caution in
CNS/Resp/CV
<12yrs (reports depression
of met. Acidosis)
Valproic Acid
20-40mg/kg IV
over 5min then
5mg/kg/h
As adult
hypotension
Pentobarbital
5mg/kg IV at
25mg/min
As adult
Titr.to EEG
ETT/CV support
Isoflurane
Via gen’l ETT
anesthesia
As adult
Titr. to EEG
ETT/CV support
CNS/Resp/CV
depression
Conclusions

Seizures are common presenting problems
to EMS.
 Status epilepticus must be treated rapidly to
avoid significant morbidity.
 Familiarity with protocols and medication
options is crucial.
Questions?
References

American College of Emergency Physicians: Clinical
policy for the initial approach to patients presenting with a
chief complaint of seizure who are not in status epilepticus.
Ann Emerg Med. May 1997;29:706-724.
 ACEP, AAN, AANS, ASN: Practice parameter:
Neuroimaging in the emergency patient presenting with
seizure (summary statement). Ann Emerg Med.
1996;28:114-118.
 Smith, BJ. Treatment of Status epilepticus. Neurologic
Clinics. May 2001;19:2
 Bradford JC, Kyriakedes CG. Evaluation of the patient
with seizures: an evidence based approach. Emergency
Medicine Clinics of North America. Feb 1999;17:1
References cont’d

Goetz. Epileptic Seizures. Textbook of Clinical Neurology,
1st ed. WB Saunders 1999. pp1062-1079
 Pollack CV. Seizures. Rosen’s Emergency Medicine:
Concepts and Clinical Practice, 5th Ed. Mosby 2002.
Pp145-149
 Hanhan UA, Fiallos MR, Orlowski JP. Status Epilepticus.
Pediatric Clinics of North America. Jun 2001;48:3
 Lahat E, Goldman M, Barr J, et al. Comparison of
intranasal midazolam with intravenous diazepam for
treating febrile seizures in children: prospective
randomised study. BMJ. July 200;321:83-86
 Hirtz D, Ashwal S, Berg A, et al. Practice parameter:
evaluating a first nonfebrile seizure in children. Neurology.
Sept 2000;55:5