Approach

Still Seizing? = Status = > 5 minutes, Realistically any ED pt still seizing on arrival

ABC – Roll to side, oxygen by mask, protect from injury

Immediate Fingerstick

Benzos

Diazepam 5 mg = Midazolam 2 mg = Lorazepam 1 mg

Midazolam 4-8 mg IV or 10 mg IM

Lorazepam 2-4 mg IV

Peds = Lorazepam 0.1 mg/kg or Midazolam 0.2 mg/kg IM/IV/IN

2nd Line AED

Keppra 60 mg/kg to max 4.5 g (adults) or 40 mg/kg to max 3g (kids)

Fospheny 20 mg/kg

Valproate 20 mg/kg

3rd Line

RSI w/ ketamine

Propofol gtt

Paralyze (succ unless LONG seizure or other risk for hyerK+)

Alternately benzo gtt or Phenobarb 20 mg/kg

Refractory Status Seizures DDx

Hypoglycemia

Hyponatremia

Hypocalcemia

Hypomagnesemia

INH Overdose = 5 GRAMS of pyridoxine IV may repeat once at 10 minutes

Meningoencephalitis

Space occupying CNS lesion

EtOH w/d

Tox: TCA, aspirin, lithium, sympathomimetic

Workup – After Seizure Stopped

History of seizures vs 1st time seizure

Syncope vs seizure (Character, prodrome, tongue biting, post ictal) – Malignant dysrhythmia ALWAYS on DDx

Trauma due to seizure?

Pregnancy?

H/o structural heart disease, malignancy or immunocompromise?

Simple alogrithm