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T.R. Eckler: my favorite acronym from
this whole article is NORSE, the patients

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that don't respond to the initial
rounds of anti-seizure medications.

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I like the idea that these patients
that I find really challenging are

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like tough old Vikings and that's why
I have to really battle with them.

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Sam: Hi everyone, and welcome
to another episode of EMPlify

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I'm your host, Sam Ashoo.

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Before we dive into this month's episode,
I want to say thank you for joining us.

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I sincerely hope that you find it to
be helpful and informative for your

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clinical practice, and I want to remind
you that you can go to ebmedicine.net

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where you will find our three journals,
Emergency Medicine Practice, Pediatric

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Emergency Medicine Practice, and Evidence
Based Urgent Care, and a multitude of

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other resources, like the EKG course,
the laceration course, interactive

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clinical pathways, just tons of
information to support your practice

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and help you in your patient care.

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And now, let's jump into
this month's episode.

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Alright, ladies and gentlemen, welcome
back to another episode of EMPlify.

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I'm your host, Sam Ashoo, and on
the other end of the microphone.

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T.R. Eckler: TR Eckler back to talk
about my favorite topic, which is

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seizures and status epilepticus.

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Sam: Nice, nice.

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If you are not a regular
listener, well then you should be.

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But if you are not, then we actually
did an article on this topic in

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children recently, the pediatric
status epilepticus, and today we

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have the pleasure of the follow-up,
which is emergency medicine

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practice September, 2025 issue on.

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Status epilepticus in adults,
this one, Dr. Marquez, Dr. Kaur,

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and Dr. Lay were the authors for
and it is an interesting topic.

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You've seen many cases of
adult status epilepticus.

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T.R. Eckler: I would tell you that this
is one of my favorite things to teach

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to students and residents, and I find
that trying to stop seizures, especially

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status where like the first line agents
aren't working, and then trying to decide

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who's in non convulsive status is such a
great challenging question that requires

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like great history, great communication
with EMS, great physical exam and just a

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continued, you know, high level of concern
and a high level to reassess the patient

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and see if they're improving or not.

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It's just a great distillation of
what doing this job well looks like.

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And I think it's a great thing that
involves so many different aspects of

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the team from, you know, nursing to the
tech that does the EEGs to lab to send

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out labs for seizure medication levels.

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It's just such a great thing that just
teaches you how to work in this system

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and how to do the best you can for people.

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Sam: Yeah, and honestly my favorite
portion of this article is the

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International League Against Epilepsy.

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Once again, I get to talk
about my favorite organization.

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If you're out there and you belong
to the International League Against

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Epilepsy, I'm still waiting for my T-shirt

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T.R. Eckler: T-shirts, we want T-shirts.

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Yes.

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Sam: I wanna be a member of the league.

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I love the name of this organization.

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T.R. Eckler: Let us make your t-shirts.

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Just literally, we will start making
t-shirts 'cause they're gonna be amazing.

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Sam: Grant me the license.

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I was happy to see that the authors
did an exhaustive review of the

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literature, like over 75 articles, and
then also pulled guidelines from the

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International League Against Epilepsy
and the Neurocritical Care Society

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and the American Epilepsy Society.

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And for the most part, all
of these guidelines are in

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agreement, which is great.

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Interestingly, most of the evidence
comes from 2019 to now because of three

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major randomized controlled trials,
which the authors mentioned EcLiPSE,

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ConSEPT, and ESETT or ESETT depending
on how you pronounce that but all

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three of them were good randomized
control studies comparing different

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medications for status epilepticus.

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And then the authors did a good job
of reminding us about the change in

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definition for status epilepticus.

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So if you're old, and I will say
like me, you remember when status

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epilepticus used to have the
definition of 30 minutes of continuous

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seizing, which is utterly ridiculous.

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No one ever waited that long to
make that diagnosis, but that

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was part of the definition.

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Now it is continuous seizing or
seizing without return of normal

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mentation before the next one begins
for five minutes or more in order

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to qualify for that diagnosis.

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And I think that is a much more
reasonable timeframe because I'm not

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fond of just sitting around watching
somebody seize on and on and on.

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And we we don't like that experience
in the emergency department.

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So a good reminder that
that definition changed.

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If you're a younger physician, you
probably learned this in residency

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or even in medical school, honestly.

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But if you're an older physician,
you may remember that it used to be a

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longer period, and really the reason
it is because of the morbidity or

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mortality, which is up to 30% for
status epilepticus considered to be

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the most extreme form of seizures.

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And that's a pretty high
mortality rate, honestly.

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So things to keep in mind when we
talk about status epilepticus are

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the classification for seizures.

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And this gets into some of the
nuance that you probably rely on

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your neurology colleagues for most.

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But TR you already touched on this.

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You've got the convulsive
and the non convulsive types.

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And if they're convulsing, you
can see evidence of a seizure,

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whether that's generalized or focal.

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And if they're non convulsive, this
is where it gets to be really quite

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difficult to make the diagnosis.

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Because if they started with a
convulsive seizure and now are no longer

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seizing, but they're altered and they
haven't regained consciousness, you're

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wondering, eh, is there still continuing
non convulsive seizure activity?

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Or sometimes it can just present with
altered mentation, bizarre behavior,

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unusual things like hallucinations
and bizarre thoughts or a change

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in their normal personality.

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These are kind of scary things
because they're very easy to miss,

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and I think the authors did a great
job of driving that point home too.

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T.R. Eckler: And I think repeated
neurologic exams is really

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what I took away from that.

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It's like there's such
a wide range of these.

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It's something where
you're gonna medicate 'em.

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Then you've gotta wait and kind of
see, because yes, the seizures have

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stopped, but now you wanna be able
to say to whoever you're kind of

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bringing this patient to next, what
does their neuro exam look like now?

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How has it changed afterwards?

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What's different?

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Are they back to baseline?

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If they're not, what else is going on?

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So I just, I liked how they, they kind of
started to break this out into categories,

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but I find that so much of it is just you
reassessing the patient and trying to see

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where this is going on you as it develops.

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Sam: Yeah, yeah.

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This is definitely somebody you're
not gonna walk away from and leave the

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bedside for any kind of duration of time.

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It's gonna take a lot of effort.

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And they're usually pretty
critical patients, honestly.

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They're going to the ICU, they're
going to neuro ICU, labor intensive.

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There's a lot of resources involved
in this evaluation and treatment plan.

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On page four, table one does a good
job of breaking down the classification

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for the International League Against
Epilepsy's classification scheme.

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I don't really we want to get into it.

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It's a little complex.

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And again, this is probably a great
discussion with your neurologist, but it

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talks about things like the semiology,
what it looks like when they're seizing,

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the etiology, if it's structural or
metabolic, what the EEG findings are,

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and then what the age of the patient are.

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Those are all the four axes that
give you the classifications for

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what kind of seizure this was.

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But for the relevant portion of the ED
evaluation, it is, are they still seizing?

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Do we think they're having convulsive
or non convulsive status, and how

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do we go about addressing that?

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When we talk about the etiology for
seizures, there are lots of different

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things when it comes to the causes, acute
and non-acute, and I thought this was

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an interesting breakdown of definitions.

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So, acute etiologies would be
anything within the past seven days

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that may have triggered the seizure.

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All things like abnormalities of sugar and
osmolality and electrolyte abnormalities

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and things like noncompliance with
medication if they have a history of

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seizure disorder or head trauma or
infections or even cerebrovascular

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events within the last seven days.

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And then the non-acute is
anything farther out from that.

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And that's the most important distinction.

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And interestingly, the authors did
mention that, you know, almost half the

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cases, we don't ever figure out why this
occurred even in status epilepticus.

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So even in the most extreme form
of seizing, despite all of the

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tests we can run,  about 45% of
the time, we're not figuring out

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what it is that caused this event.

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T.R. Eckler: I took away from this
section just a couple of things that

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I thought added to my workup for these
patients, which is, I wasn't thinking as

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much about asking about sleep patterns
for these patients, but I think in

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this day and age, especially given
how much caffeine people are taking.

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Especially given the prevalence of,
you know, more and more stimulants that

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people are using for ADHD, I think that
sleep is not at an all time high in

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terms of how well people are sleeping.

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So I think that that's something I'm gonna
start at least looking more at to see.

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And then I also think I wasn't looking
at ammonia levels as something that

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that was gonna cause seizures, and
I think that that's gonna be more

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on my workup for these patients.

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I would like to know that my favorite
acronym from this whole article is

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NORSE, the patients that don't respond
to the initial rounds of anti-seizure

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medications, and therefore they're
diagnosed with new onset refractory status

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epilepticus, I like the idea that these
patients that I find really challenging

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are like tough old Vikings and that's
why I have to really battle with them.

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So I find that that's like a
really just a, that's got a

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lot of layers to that acronym.

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I don't like SE for status
epilepticus, I just want them

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to commit to calling it status.

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'Cause like they've got status
over status migrainosus, no one's

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talking about migraine status.

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So status is status and I think
they should just stick with that

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Sam: Unless you're talking to a
pulmonologist, then it's asthma.

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T.R. Eckler: Status asthmaticus.

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Sam: I mean, there is another one.

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T.R. Eckler: No, I still think status
is seizures as much as pulm wants it.

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Everyone, everyone wants it.

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No, it's, it's seizures.

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I'm calling it.

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That's it.

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Sam: It is kind of reminiscent of
like acute chest syndrome being ACS.

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Right?

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And you're like, no ACS is taken already,
I'm sorry, that's acute coronary syndrome.

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You

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can't use that acronym.

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T.R. Eckler: Like severe asthma
exacerbation, critical asthma

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exacerbation, however you want go
for that, but status is is seizures.

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That's it.

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I'm calling it.

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Sam: Table four on page six
goes through some of the known

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causes of status epilepticus.

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So obviously in the acute phase, if
they're already on seizure medications,

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then if they're not taking them,
that's one of the primary causes.

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So, non-compliance with medications, there
is the, the idiopathic, we have no idea

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what it is that's causing this category.

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Drugs.

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Lots of drug interactions
can lower seizure thresholds.

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So ask about recent prescribing history.

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Have they started any new medications?

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Are they on antibiotics?

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Have they had any recent illnesses?

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Because not just the medications to
treat those illnesses, but the illnesses

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themselves can also trigger seizures.

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Like you mentioned, sleep disturbances.

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That can happen if you're sick.

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Fever, inflammatory reactions,
all of these things.

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And then the medications we
prescribe them for those symptoms.

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Metabolic issues, structural
causes, toxins, certainly, whether

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their exposures or intentional or
unintentional, infections, and then

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intrinsic conditions with known
epilepsy, like you mentioned, sleep

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deprivation being the primary one there.

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And then there are some remote causes.

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So these are things that would be
considered maybe non-acute, even

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outside of seven day time period.

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Things like post-traumatic,
post encephalitic, post-stroke.

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Anytime there's any kind of neuro
injury, patients are at higher risk

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for seizures and status epilepticus.

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Progressive etiologies like brain tumors.

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Myoclonic epilepsy syndromes and dementias
and neurodegenerative conditions.

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Those are all things that will make
you more prone to new onset seizures

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and status epilepticus as well.

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And so it's a good differential to
keep in mind when you are treating

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someone with status epilepticus.

228
00:12:04,881 --> 00:12:10,921
And then table five also includes
specific diagnoses that can cause status

229
00:12:10,951 --> 00:12:14,371
epilepticus, including things like
intracranial hemorrhage, hypoglycemia,

230
00:12:15,237 --> 00:12:19,817
acute hydrocephalus, metabolic
derangement of sugar and electrolytes,

231
00:12:19,937 --> 00:12:22,217
drug toxicities and withdrawal.

232
00:12:22,247 --> 00:12:24,887
So we didn't mention that one
already, but alcohol withdrawal,

233
00:12:25,047 --> 00:12:26,817
amphetamine, the stimulant withdrawals.

234
00:12:27,117 --> 00:12:28,857
Syncope is an interesting one.

235
00:12:28,987 --> 00:12:32,347
It's in the differential for status
epilepticus, but it kind of is a

236
00:12:32,347 --> 00:12:35,257
good reminder that there are other
things that can be seizure mimics,

237
00:12:35,287 --> 00:12:36,457
and we'll get to that in a moment.

238
00:12:36,887 --> 00:12:39,677
Psychogenic, non-epileptic seizures.

239
00:12:39,897 --> 00:12:44,869
Those can be very difficult differentiate
from true seizures and often require

240
00:12:44,869 --> 00:12:49,129
things like video EEG monitoring so
they can see what's going on with

241
00:12:49,129 --> 00:12:51,109
the patient while looking at the EEG.

242
00:12:51,389 --> 00:12:54,329
T.R. Eckler: Sometimes they're
easy, Sam, sometimes they're not.

243
00:12:54,389 --> 00:12:55,049
Not easy.

244
00:12:55,259 --> 00:12:59,369
Sometimes the patient starts doing a
fake seizure and you can yell really loud

245
00:12:59,369 --> 00:13:02,669
their name and they'll stop and look at
you and you can say, hi, welcome back.

246
00:13:02,720 --> 00:13:02,900
Sam: Yeah.

247
00:13:02,950 --> 00:13:04,349
T.R. Eckler: Doesn't seem
like that was a seizure.

248
00:13:04,559 --> 00:13:06,869
And then it's a good time for
the family to talk about that.

249
00:13:07,109 --> 00:13:10,589
But sometimes people do really
convincing seizures that aren't

250
00:13:10,589 --> 00:13:11,999
seizures, and it's tricky.

251
00:13:11,999 --> 00:13:16,639
So I don't think people should feel any
sort of way that like they definitely

252
00:13:16,639 --> 00:13:20,119
know a seizure is psychogenic or not
'cause I think sometimes upstairs teams

253
00:13:20,299 --> 00:13:24,019
will be kind of questioning of that,
but it is not always easy to tell.

254
00:13:24,019 --> 00:13:24,834
But sometimes you can.

255
00:13:25,534 --> 00:13:25,774
Sam: Yeah.

256
00:13:25,774 --> 00:13:30,204
And that, you know, the psychogenic
non-epileptic seizures are not

257
00:13:30,204 --> 00:13:32,394
necessarily synonymous with malingering.

258
00:13:32,394 --> 00:13:34,884
So you know the intent
is not necessarily there.

259
00:13:35,004 --> 00:13:38,274
It's not that the patient is
trying to fool you into the fact

260
00:13:38,274 --> 00:13:39,294
that they're having a seizure.

261
00:13:39,294 --> 00:13:42,234
It's just that they have this
manifestation that looks like a seizure,

262
00:13:42,354 --> 00:13:44,034
and we're trying to determine the intent.

263
00:13:44,214 --> 00:13:47,304
And so that's where that name
comes from, that it's psychogenic.

264
00:13:47,304 --> 00:13:51,669
It's not necessarily epileptiform or
abnormal electrical activity of the brain.

265
00:13:51,859 --> 00:13:52,702
But yeah, you're right.

266
00:13:52,752 --> 00:13:55,396
And the authors, we'll get into this in
a second in the physical exam section,

267
00:13:55,606 --> 00:13:59,656
they did talk about some things that
are typical of a true seizure and

268
00:13:59,656 --> 00:14:01,456
typical of a non-epileptic seizure.

269
00:14:01,916 --> 00:14:07,066
Movement disorders, dyskinesias, severe
Parkinson's disease, and Guillain-Barré

270
00:14:07,086 --> 00:14:10,196
syndrome, all things that should stay
in your differential diagnosis when

271
00:14:10,196 --> 00:14:14,124
you're thinking about status epilepticus
because they can increase tone and kind

272
00:14:14,124 --> 00:14:17,014
of present with status epilepticus mimics.

273
00:14:17,074 --> 00:14:18,528
So things to keep in mind.

274
00:14:18,778 --> 00:14:21,778
The authors did do a good job,
I think, of addressing syncope.

275
00:14:21,778 --> 00:14:25,588
So, syncope, the loss of consciousness,
often comes with some shaking

276
00:14:25,588 --> 00:14:28,768
and some, you know, seizure-like
activity, and then the person regains

277
00:14:28,768 --> 00:14:32,463
consciousness, and then there's no
continued altered mental status.

278
00:14:32,463 --> 00:14:34,053
As soon as they wake up, they're better.

279
00:14:34,273 --> 00:14:36,883
And that tells you, okay,
this wasn't a true seizure.

280
00:14:36,883 --> 00:14:39,283
This was just bad perfusion to the brain.

281
00:14:39,343 --> 00:14:41,893
We weren't getting enough blood
for a few seconds, hopefully.

282
00:14:42,213 --> 00:14:48,243
The description of the tonic-clonic,
jerking, tongue biting, mouth

283
00:14:48,243 --> 00:14:50,203
clenched, eyes deviated.

284
00:14:50,363 --> 00:14:53,553
Those are the kinds of things you're
gonna elicit from history from a

285
00:14:53,553 --> 00:14:56,973
bystander that will kind of send
you down the, the seizure route

286
00:14:57,133 --> 00:14:58,783
instead of a mimic like syncope.

287
00:14:59,483 --> 00:15:02,946
In the pre-hospital setting there are s
ome key things that the authors pointed

288
00:15:02,946 --> 00:15:06,366
out that our pre-hospital colleagues
should be doing and would be helpful.

289
00:15:06,466 --> 00:15:09,526
Number one is always airway,
breathing, and circulation.

290
00:15:10,226 --> 00:15:14,186
Number two is pharmacologic
treatment to abort the seizure.

291
00:15:14,186 --> 00:15:16,796
So this kind of seems like a
no-brainer, but we're not just

292
00:15:16,796 --> 00:15:18,416
gonna wait for the seizure to end.

293
00:15:18,416 --> 00:15:20,906
We're gonna give something
to terminate the seizure and

294
00:15:20,906 --> 00:15:22,316
hopefully prevent a second one.

295
00:15:22,666 --> 00:15:26,476
Number three is preventing additional
trauma to the seizing patient.

296
00:15:26,476 --> 00:15:31,136
So this can happen when someone is
seizing and falls off a couch or someone

297
00:15:31,136 --> 00:15:33,776
is seizing and falls out of a chair
and smacks their head on the glass

298
00:15:33,776 --> 00:15:35,186
table on the way down on the floor.

299
00:15:35,516 --> 00:15:39,146
Or if they're in the EMS stretcher and
they haven't been completely secured and

300
00:15:39,146 --> 00:15:42,176
they start to have another seizure again,
they fall fall off the stretcher while

301
00:15:42,176 --> 00:15:43,706
you're moving them out to the ambulance.

302
00:15:43,706 --> 00:15:46,736
You know, those things do happen
and you just gotta be super careful.

303
00:15:46,886 --> 00:15:48,926
If they've had one seizure,
they may have another one.

304
00:15:48,926 --> 00:15:50,156
So you gotta anticipate that.

305
00:15:50,856 --> 00:15:54,876
And lastly, the fourth item was gathering
available medical history from the

306
00:15:54,876 --> 00:15:59,956
scene, including medications, pill
bottles, and signs of drug use, right?

307
00:15:59,956 --> 00:16:03,256
So in addition to getting the history
from any people that are around, you're

308
00:16:03,256 --> 00:16:07,366
gonna wanna look for all of those
items because they can clue you into

309
00:16:07,366 --> 00:16:11,006
what may be the cause, and that's very
helpful information to us in the ED.

310
00:16:11,356 --> 00:16:13,606
T.R. Eckler: I would add family
contact information to that.

311
00:16:13,816 --> 00:16:16,786
'cause I always wanna try to get
some kind of story from family.

312
00:16:16,786 --> 00:16:19,576
Like, Hey, is the patient
really taking their medications?

313
00:16:19,756 --> 00:16:23,086
What seizure meds have they responded
well to in the past, if you know which

314
00:16:23,086 --> 00:16:24,526
ones did they not respond well to?

315
00:16:24,706 --> 00:16:27,316
I find that directs a lot of
my therapy more often than not.

316
00:16:27,618 --> 00:16:27,738
Sam: Yep.

317
00:16:28,008 --> 00:16:33,121
I thought also the authors did a good job
reminding us that because of suppression

318
00:16:33,121 --> 00:16:37,381
of the gag reflex during status
epilepticus, the patient should be placed

319
00:16:37,381 --> 00:16:39,121
in that left lateral decubitus position.

320
00:16:39,301 --> 00:16:41,761
This can be really hard if
they're actively seizing.

321
00:16:41,951 --> 00:16:44,471
But something to think about, even
if it's a little bit of a tilt

322
00:16:44,471 --> 00:16:48,201
and shove a few pillows underneath
them and that it's not recommended

323
00:16:48,201 --> 00:16:50,031
to stick anything in their mouth.

324
00:16:50,031 --> 00:16:50,301
Right?

325
00:16:50,301 --> 00:16:53,331
You don't wanna put in a bite block
or try and force open a clenched

326
00:16:53,391 --> 00:16:57,981
jaw, you will lose fingers that way
if you are a paramedic or an EMT or

327
00:16:57,981 --> 00:16:59,661
even a first responder of any sort.

328
00:16:59,841 --> 00:17:03,771
So don't go putting anything into a
clenched mouth, just turn 'em on their

329
00:17:03,771 --> 00:17:05,521
side and a little supportive care.

330
00:17:05,581 --> 00:17:10,666
If you do have to give them something
because of hypoxia or their respiratory

331
00:17:10,666 --> 00:17:14,056
drive is not very good, you can use
a nasal pharyngeal airway, you know,

332
00:17:14,116 --> 00:17:15,316
that's a, that's a good device.

333
00:17:15,316 --> 00:17:17,506
Goes in the nose and goes all the
way to the back of the pharynx,

334
00:17:17,656 --> 00:17:21,146
gets that tongue outta the way and
helps with hypoxia sometimes, and

335
00:17:21,146 --> 00:17:22,646
then a little supplemental oxygen.

336
00:17:23,346 --> 00:17:25,266
And then you follow your ACLS protocols.

337
00:17:25,266 --> 00:17:28,596
So obviously if all of that doesn't
work and you have to medicate and

338
00:17:28,596 --> 00:17:30,216
intubate, that's what you gotta do.

339
00:17:30,576 --> 00:17:33,066
So you get aggressive and
you get aggressive quickly.

340
00:17:33,766 --> 00:17:39,196
Point of care blood sugar is very, very
critical in this scenario because that

341
00:17:39,316 --> 00:17:43,966
can be an easily fixable cause for status
epilepticus that you don't wanna miss.

342
00:17:44,666 --> 00:17:47,171
T.R. Eckler: You lose points for
intubating hypoglycemic people.

343
00:17:47,265 --> 00:17:48,555
That's always a negative one point.

344
00:17:48,796 --> 00:17:49,126
Sam: Yeah.

345
00:17:49,826 --> 00:17:51,440
And then IV access.

346
00:17:51,560 --> 00:17:55,700
This is very helpful, especially if you're
gonna go down the ACLS protocol pathway.

347
00:17:55,920 --> 00:18:01,260
But you know, if you are unable to get
it, there are IM intranasal options.

348
00:18:01,390 --> 00:18:02,080
IO.

349
00:18:02,240 --> 00:18:05,233
There's all kinds of other
methods for access that are

350
00:18:05,233 --> 00:18:06,793
available to you pre-hospital.

351
00:18:06,793 --> 00:18:11,193
So you guys are the experts when it
comes to that and staying adept at using

352
00:18:11,193 --> 00:18:14,793
all of those tools and knowing which
medications, especially like midazolam,

353
00:18:14,793 --> 00:18:18,633
which can be given just about in any way
you could possibly get it into the body

354
00:18:18,913 --> 00:18:21,013
is very effective in terminating seizures.

355
00:18:21,713 --> 00:18:25,283
T.R. Eckler: I am falling out of love
with intranasal medications 'cause

356
00:18:25,283 --> 00:18:29,093
I find that often I don't get all
of the medicine in that I want to.

357
00:18:29,213 --> 00:18:33,838
And I think that they made a great
case in this article for the efficacy

358
00:18:33,838 --> 00:18:38,548
based on research and trials of
intramuscular midazolam, especially in

359
00:18:38,548 --> 00:18:41,308
the pre-hospital setting, where before
you're even worried about getting the

360
00:18:41,308 --> 00:18:44,758
IV, if they're seizing you check the
sugar, bang, give 'em some midazolam

361
00:18:45,088 --> 00:18:46,738
because then you're gonna stop them.

362
00:18:46,738 --> 00:18:49,985
And I think the majority of
cases it was even more effective,

363
00:18:49,985 --> 00:18:51,275
I think, than IV lorazepam.

364
00:18:51,635 --> 00:18:54,860
So I took that as like
good drug, short acting.

365
00:18:54,890 --> 00:18:58,010
I think intramuscular is a good, safe
way to give that drug 'cause I think it

366
00:18:58,010 --> 00:19:01,160
comes on in a nice fashion that doesn't
usually gimme respiratory depression.

367
00:19:01,430 --> 00:19:05,180
And I think that that was my big
takeaway from pre-hospital or from if

368
00:19:05,180 --> 00:19:07,910
they get to the ER and I don't have an
IV, that's where I'm gonna go first.

369
00:19:07,981 --> 00:19:08,311
Sam: Yeah.

370
00:19:08,701 --> 00:19:08,911
Yeah.

371
00:19:08,911 --> 00:19:12,681
I mean, if you have never tried
to put an IV in someone in the

372
00:19:12,681 --> 00:19:17,011
back of a truck, imagine them now
seizing while you're doing that.

373
00:19:17,101 --> 00:19:19,141
It's just, it seems impossible.

374
00:19:19,171 --> 00:19:23,321
Somehow our pre-hospital colleagues
can still get them which is amazing and

375
00:19:23,321 --> 00:19:24,971
a testament to their skill, honestly.

376
00:19:25,161 --> 00:19:28,581
But yes, by all means, give them
the IM midazolam and then go after

377
00:19:28,581 --> 00:19:30,051
the IV when they've stopped seizing.

378
00:19:30,051 --> 00:19:31,156
It'll just make it that much easier.

379
00:19:31,666 --> 00:19:35,536
And hopefully that's already in your
pre-hospital protocols for treating

380
00:19:35,536 --> 00:19:37,306
status epilepticus or a seizure.

381
00:19:38,006 --> 00:19:41,886
So yes, midazolam, check the
blood glucose, get the history,

382
00:19:42,106 --> 00:19:43,926
bring them on over to the ED.

383
00:19:43,946 --> 00:19:48,086
And the dosing is written there
in the article for adult and

384
00:19:48,086 --> 00:19:50,456
pediatric dosing for IM Midazolam.

385
00:19:50,676 --> 00:19:53,816
It is perfectly safe and the
authors did note it terminates

386
00:19:53,816 --> 00:19:59,806
seizures 73% of the time versus IV
lorazepam, which was 63% of the time.

387
00:20:00,016 --> 00:20:02,566
And you know, it seems like
that's only a 10% change, but that

388
00:20:02,566 --> 00:20:04,246
was statistically significant.

389
00:20:04,246 --> 00:20:05,649
So  it's worthwhile.

390
00:20:05,649 --> 00:20:09,099
And if it's gonna delay stopping
the seizure, just give it to 'em

391
00:20:09,099 --> 00:20:10,419
IM And then try and get your IV.

392
00:20:11,056 --> 00:20:13,696
T.R. Eckler: I took that away from
this article too, in the, the theory

393
00:20:13,696 --> 00:20:17,416
and some of the pathophys they talked
about, that the longer you wait to

394
00:20:17,416 --> 00:20:21,826
give medication, the more likely it
is to not be successful in terminating

395
00:20:21,826 --> 00:20:23,656
a seizure in a patient with status.

396
00:20:23,746 --> 00:20:27,841
And I think that made me more inclined
to get benzo into the person as fast

397
00:20:27,841 --> 00:20:31,136
as as I can, and I think intramuscular
Midazolam seems like that's the way.

398
00:20:31,836 --> 00:20:34,666
Sam: That was a great discussion
that we didn't really touch on.

399
00:20:34,666 --> 00:20:39,196
But the pathophysiology there is that
the longer that the brain is seizing,

400
00:20:39,386 --> 00:20:43,226
the more changes in biochemistry you
get, the receptors that are on the

401
00:20:43,226 --> 00:20:45,726
outside of the cells are downregulated.

402
00:20:45,726 --> 00:20:47,796
Those GABA receptors
are starting to go away.

403
00:20:48,016 --> 00:20:51,736
And so the medication, the benzos that
we give that are supposed to attach to

404
00:20:51,736 --> 00:20:53,686
those receptors, just have less targets.

405
00:20:53,686 --> 00:20:57,406
So the longer you wait, the more
ineffective those medications get and

406
00:20:57,406 --> 00:21:01,541
the more likely you are to head down
the intubation and, you know, initiate

407
00:21:01,541 --> 00:21:05,691
a coma route, which is the ultimate
thing that we're trying to avoid, but

408
00:21:05,751 --> 00:21:07,611
is sometimes necessary in these cases.

409
00:21:08,311 --> 00:21:08,611
Okay.

410
00:21:08,611 --> 00:21:11,161
When they get to the emergency
department, the history we touched

411
00:21:11,161 --> 00:21:12,781
on is very, very important.

412
00:21:12,781 --> 00:21:16,501
So assuming you have the time and
there's family available or some other

413
00:21:16,501 --> 00:21:19,411
resource, you want to ask about all
of these things we just mentioned,

414
00:21:19,411 --> 00:21:23,371
toxin exposure, recent trauma,
recent hospitalizations for stroke.

415
00:21:23,581 --> 00:21:24,871
Do they have a brain tumor?

416
00:21:25,021 --> 00:21:26,371
Is this a known problem?

417
00:21:26,371 --> 00:21:27,361
Is it a new problem?

418
00:21:27,361 --> 00:21:30,181
All of these questions you're gonna
ask, and hopefully if they come by

419
00:21:30,181 --> 00:21:33,391
ambulance, EMS is gonna provide you
with the answers to most of these.

420
00:21:33,391 --> 00:21:38,781
And then when we get to the physical
exam portion, this is where now you're

421
00:21:38,781 --> 00:21:42,371
starting to do those serial exams
again and again and again to look for

422
00:21:42,371 --> 00:21:44,901
changes over time as they're seizing.

423
00:21:44,901 --> 00:21:47,031
You're gonna note what kind of seizure.

424
00:21:47,211 --> 00:21:50,721
It's very helpful, I think, for our
neurology colleagues to note the

425
00:21:50,721 --> 00:21:53,091
laterality of the seizure activity.

426
00:21:53,091 --> 00:21:56,241
So if it's not just a completely
generalized seizure and it's focal,

427
00:21:56,521 --> 00:21:59,971
making a note of yes, it was their
left arm and their left leg that

428
00:21:59,971 --> 00:22:03,031
was hypertonic and shaking and
had some tonic-clonic activity.

429
00:22:03,251 --> 00:22:06,581
But their right side seemed completely
flacid and their eyes were deviated,

430
00:22:06,581 --> 00:22:09,551
you know, to the left or to the
right, those are kind of important

431
00:22:09,551 --> 00:22:14,351
things to note because they can
become clues that you need to then

432
00:22:14,531 --> 00:22:15,941
chase something down with imaging.

433
00:22:16,541 --> 00:22:18,011
And we'll talk about
that in just a second.

434
00:22:18,250 --> 00:22:20,350
T.R. Eckler: I would add that I think
it's important to ask family too,

435
00:22:20,350 --> 00:22:23,500
is this what their seizures usually
look like or is this different?

436
00:22:23,680 --> 00:22:26,800
Because if it's different, then I think
that heightens me a little more that

437
00:22:26,800 --> 00:22:28,300
maybe there's something else going on.

438
00:22:28,630 --> 00:22:32,475
And then again, I, I think that this
is the time where you ask family,

439
00:22:32,775 --> 00:22:35,325
you know, while you're examining the
patient, what medicines they're on

440
00:22:35,325 --> 00:22:38,085
and what medicines they've responded
well to or poorly in the past.

441
00:22:38,295 --> 00:22:42,045
I had a family recently that really asked
me not to give Keppra because they said

442
00:22:42,045 --> 00:22:46,665
the patient has a lot of psychiatric
issues coming off of Keppra afterwards,

443
00:22:46,845 --> 00:22:50,655
so I ended up going with fosphenytoin
instead of Keppra after talking with

444
00:22:50,655 --> 00:22:54,945
neurology, because it seemed like that
was probably the best thing for the

445
00:22:54,945 --> 00:22:58,575
patient, even though the loading time
on  fosphenytoin is significantly slower.

446
00:22:58,835 --> 00:22:59,085
Sam: Yeah.

447
00:22:59,465 --> 00:23:03,085
And you can also ask about things
like, you know, have they had multiple

448
00:23:03,085 --> 00:23:04,875
seizures like this in the past?

449
00:23:05,231 --> 00:23:08,411
And sometimes I find that to be kind
of something that just reduces my

450
00:23:08,411 --> 00:23:11,188
anxiety when the, parent says, oh
yeah, you know, usually they have

451
00:23:11,188 --> 00:23:16,568
these stacked 5, 6, 7 in a row over the
course of a few hours, and I go okay.

452
00:23:16,658 --> 00:23:17,108
Okay.

453
00:23:17,134 --> 00:23:20,524
So now I know what we're dealing with,
you know, oh, they're on five different

454
00:23:20,524 --> 00:23:24,604
anti-epileptics and we're gonna run
the gamut of the meds with them,

455
00:23:24,604 --> 00:23:26,424
but it's been difficult to control.

456
00:23:26,614 --> 00:23:29,404
That's very, very helpful
information to elicit for sure.

457
00:23:30,104 --> 00:23:33,996
In the physical exam section
also, you wanna note the response

458
00:23:33,996 --> 00:23:35,346
to any medications you've given.

459
00:23:35,376 --> 00:23:37,236
You know, sometimes we rely
on our nursing colleagues.

460
00:23:37,236 --> 00:23:41,196
We say, okay, go give them 10 of Midazolam
right now and then I'll be right back.

461
00:23:41,226 --> 00:23:43,236
And, you know, if the nurse comes up
and says, Hey, great news, they've

462
00:23:43,236 --> 00:23:47,286
stopped seizing, I have personally
had these scenarios where it is

463
00:23:47,286 --> 00:23:48,636
thought that they stopped seizing.

464
00:23:48,636 --> 00:23:51,006
And then I walk in and I
open their eyes and I go, eh,

465
00:23:51,066 --> 00:23:52,836
their eyes are still deviated.

466
00:23:52,956 --> 00:23:55,236
They're not as tense, but
I'm gonna pick up their arms.

467
00:23:55,236 --> 00:23:59,436
And there's still some increased
tone in these extremities, and this

468
00:23:59,436 --> 00:24:00,966
seizure hasn't actually stopped.

469
00:24:00,966 --> 00:24:02,496
They're just not overtly shaking.

470
00:24:02,496 --> 00:24:05,666
So the subtleties matter when
it comes to this examination.

471
00:24:05,666 --> 00:24:07,976
You don't have to pull out your
reflex hammer, but you do have to

472
00:24:07,976 --> 00:24:11,786
go and pick up the arm or the leg
and check the tone, look at the eyes

473
00:24:11,956 --> 00:24:14,266
and most of the time, I think you'll
get your answer pretty quickly.

474
00:24:14,966 --> 00:24:17,426
T.R. Eckler: And I think like to your
point too, I think this is something

475
00:24:17,426 --> 00:24:20,966
where we're always kind of really highly
suspicious and the data backs this up.

476
00:24:20,966 --> 00:24:25,206
Like I think 50% of patients that
aren't coming back to normal, are

477
00:24:25,206 --> 00:24:26,766
still in non convulsive status.

478
00:24:26,766 --> 00:24:30,571
So we're chasing the right fear
here, like this is not something

479
00:24:30,571 --> 00:24:33,361
where like, you know, one in a
hundred or one in a thousand.

480
00:24:33,551 --> 00:24:35,981
These patients are still
having some signs of seizures.

481
00:24:36,191 --> 00:24:39,581
So like your desire to escalate
and keep going and push further

482
00:24:39,581 --> 00:24:41,401
is rightly, I think, justified.

483
00:24:41,548 --> 00:24:41,818
Sam: Yeah.

484
00:24:41,968 --> 00:24:42,688
Yeah, great point.

485
00:24:42,718 --> 00:24:43,498
Not a zebra.

486
00:24:43,558 --> 00:24:45,873
It definitely occurs and it occurs a lot.

487
00:24:46,573 --> 00:24:50,323
There is a good table on page
nine about laboratory testing.

488
00:24:50,323 --> 00:24:53,833
So once you've gotten past the physical
exam and we're jumping into diagnostics,

489
00:24:54,223 --> 00:24:58,813
everybody's getting a very broad set
of labs, which includes the metabolic

490
00:24:58,813 --> 00:25:02,573
profile but a finger stick glucose, if
it wasn't already done by EMS or they

491
00:25:02,573 --> 00:25:05,908
didn't come in by EMS, that's something
you're gonna do first, right away.

492
00:25:06,188 --> 00:25:10,148
A complete blood cell count looking for
leukocytosis and signs of infection.

493
00:25:10,448 --> 00:25:13,088
Typically seizures can even
cause transient leukocytosis.

494
00:25:13,088 --> 00:25:15,608
So just an elevated white blood cell
count by itself doesn't mean it's

495
00:25:15,608 --> 00:25:17,678
infectious, but something to keep in mind.

496
00:25:18,028 --> 00:25:22,274
The comprehensive metabolic profile,
which most of time does not include your

497
00:25:22,274 --> 00:25:26,404
ammonia, so if you're gonna get some liver
functions, adding the ammonia is helpful.

498
00:25:26,584 --> 00:25:30,124
Sometimes the ammonia is just high because
of the anti-epileptics they're taking too.

499
00:25:30,304 --> 00:25:33,714
'Cause that can affect liver function
depending on which agent they're taking.

500
00:25:33,714 --> 00:25:34,074
So

501
00:25:34,198 --> 00:25:36,268
T.R. Eckler: Also doesn't give
you a magnesium level, so you

502
00:25:36,268 --> 00:25:38,998
gotta add a magnesium on top
if, if you're chasing that.

503
00:25:39,294 --> 00:25:40,134
Sam: Yeah, for sure.

504
00:25:40,834 --> 00:25:44,588
Urine is helpful because it can be
a source for infection, but also if

505
00:25:44,588 --> 00:25:48,038
you're doing urine toxicity screens
instead of serum toxicity screens,

506
00:25:48,158 --> 00:25:51,038
you need to know if they have
those metabolites in their urine.

507
00:25:51,408 --> 00:25:53,178
Again, not a hundred percent.

508
00:25:53,178 --> 00:25:55,398
There are a lot of things that'll
give you false positives, so make

509
00:25:55,398 --> 00:25:56,658
sure you, you're aware of that.

510
00:25:57,064 --> 00:26:00,844
Serum levels for medications and
for exposures, so toxicity, things

511
00:26:00,844 --> 00:26:03,804
like Tylenol and alcohol and,

512
00:26:03,854 --> 00:26:04,344
T.R. Eckler: Lithium.

513
00:26:04,566 --> 00:26:05,016
Sam: Lithium.

514
00:26:05,016 --> 00:26:05,466
Yes.

515
00:26:05,466 --> 00:26:06,546
Yes, absolutely.

516
00:26:06,694 --> 00:26:07,204
T.R. Eckler: Great one.

517
00:26:07,879 --> 00:26:11,419
I think in this day and age too,
there's such a challenge of following

518
00:26:11,419 --> 00:26:12,919
up with primary care and neurology.

519
00:26:13,099 --> 00:26:16,759
I've started sending more and more seizure
drug levels, and I just had a patient

520
00:26:16,759 --> 00:26:20,479
bounce back who was a seizure patient
who wasn't able to follow up, still

521
00:26:20,479 --> 00:26:23,359
felt like she was gonna have a seizure,
felt like she had prodromal stuff, and

522
00:26:23,359 --> 00:26:26,929
I got to see that her Keppra level was
therapeutic, but she was still kind of

523
00:26:27,079 --> 00:26:28,699
having a sense of breakthrough seizures.

524
00:26:28,699 --> 00:26:30,289
So I got to kind of adjust.

525
00:26:30,289 --> 00:26:33,559
I got to kind of help her get better,
closer follow up, but I felt like

526
00:26:33,599 --> 00:26:36,359
it answered the question of her
compliance, so I think it's gonna help

527
00:26:36,359 --> 00:26:39,899
her get on a second line agent if she
kinda continues to have symptoms or

528
00:26:39,899 --> 00:26:41,309
adjust her medication where it is now.

529
00:26:41,791 --> 00:26:42,331
Sam: I like that.

530
00:26:42,511 --> 00:26:43,201
I like that a lot.

531
00:26:43,291 --> 00:26:46,651
Yeah, it kind of takes a non-compliance
out of the picture and really kinda lends

532
00:26:46,651 --> 00:26:50,131
validity to the fact that this person's
actually trying and has been compliant.

533
00:26:50,221 --> 00:26:50,701
That's good.

534
00:26:50,809 --> 00:26:53,389
T.R. Eckler: They're send out tests and
I think a lot of times we tend to brush

535
00:26:53,389 --> 00:26:57,049
off send off tests in the ER, but I think
that this is gonna help these patients

536
00:26:57,199 --> 00:27:01,583
get better care when they kind of continue
to follow up even if they're just coming

537
00:27:01,583 --> 00:27:04,493
back to the ER 'cause you can make
better decisions if you have better data.

538
00:27:05,193 --> 00:27:05,823
Sam: Excellent point.

539
00:27:06,523 --> 00:27:09,189
Lactate levels, prolactin levels.

540
00:27:09,189 --> 00:27:13,089
Now these are sometimes measured
10 to 20 minutes after a seizure

541
00:27:13,089 --> 00:27:18,849
and have a sensitivity and a
specificity about 53% and 93%.

542
00:27:18,849 --> 00:27:20,196
So it's not perfect.

543
00:27:20,196 --> 00:27:23,431
Just because they don't have an elevated
prolactin level doesn't mean they

544
00:27:23,431 --> 00:27:25,081
weren't having a legitimate seizure.

545
00:27:25,301 --> 00:27:28,931
But if they do, again, it can help you
in that differential, especially if

546
00:27:28,931 --> 00:27:32,307
you're considering something like the
psychogenic, non-epileptic variety.

547
00:27:33,007 --> 00:27:36,037
Creatinine kinase because
of rhabdo, which can happen,

548
00:27:36,037 --> 00:27:37,387
especially with prolonged seizures.

549
00:27:37,387 --> 00:27:40,237
And since we're talking about status
epilepticus, if they're continually

550
00:27:40,237 --> 00:27:42,937
seizing for a long period of time,
something you need to be aware of.

551
00:27:42,937 --> 00:27:45,637
They can develop the rhabdomyolysis
and acute kidney injury.

552
00:27:45,987 --> 00:27:49,987
Troponin is interesting actually, and
it's not one that I think about initially

553
00:27:50,037 --> 00:27:55,137
in my laboratory battery for status
epilepticus, but it does drive home

554
00:27:55,137 --> 00:28:00,507
the point that if there is concern that
they had syncope first and that they

555
00:28:00,507 --> 00:28:04,617
maybe had multiple seizures instead
of the continuous seizure, maybe this

556
00:28:04,617 --> 00:28:08,607
is cardiogenic, maybe they're having
some kind of arrhythmia each time

557
00:28:08,607 --> 00:28:10,917
that we see a seizure on the outside.

558
00:28:11,167 --> 00:28:14,107
And the only point there was
that if the troponin's elevated,

559
00:28:14,107 --> 00:28:17,966
you need to repeat it and maybe
consider further cardiac testing.

560
00:28:18,276 --> 00:28:20,256
So it's a good point to drive home.

561
00:28:20,956 --> 00:28:24,132
Cultures if they're febrile,
and then pregnancy test, if

562
00:28:24,132 --> 00:28:25,812
they're within the age range.

563
00:28:25,842 --> 00:28:30,702
That is a critical test to obtain because
the treatment pathway takes a giant

564
00:28:30,702 --> 00:28:32,742
left turn if the patient is pregnant.

565
00:28:33,442 --> 00:28:37,102
T.R. Eckler: And I think that
sometimes blood tests take a long time.

566
00:28:37,102 --> 00:28:41,272
So this is my annual reminder
that most rapid urine cartridges

567
00:28:41,272 --> 00:28:44,092
in the United States are dual
certified for blood and urine.

568
00:28:44,272 --> 00:28:47,482
So you can just take whole blood, put
it on that cartridge, and it will give

569
00:28:47,482 --> 00:28:50,032
you an answer as to whether the patient
is pregnant in just a couple of minutes.

570
00:28:50,866 --> 00:28:53,956
So if you've got questions and you're
really worried, just have the lab

571
00:28:53,956 --> 00:28:56,116
send you one of those cartridges
and you can know right away.

572
00:28:56,417 --> 00:28:56,837
Sam: There you go.

573
00:28:57,257 --> 00:29:00,907
May have to do it yourself if the
lab tech is not allowed to do it,

574
00:29:00,967 --> 00:29:02,377
but doesn't mean you can't do it.

575
00:29:02,777 --> 00:29:03,917
Alright, let's talk about imaging.

576
00:29:03,977 --> 00:29:08,317
So you know, status epilepticus, I think
most people are going to get some kind

577
00:29:08,317 --> 00:29:13,017
of imaging especially if they have an
unusual change and this is not their norm.

578
00:29:13,067 --> 00:29:15,407
It's hard to believe that it
will be the norm for anybody.

579
00:29:15,407 --> 00:29:18,927
But the point driven, I think, by the
American College of Emergency Physicians

580
00:29:18,927 --> 00:29:22,227
is that most of these patients are
gonna get a CT scan without contrast.

581
00:29:22,227 --> 00:29:24,027
That's what we have
available in our department.

582
00:29:24,247 --> 00:29:27,972
And then at some point they'll go
on to get MRI imaging, you know,

583
00:29:27,972 --> 00:29:31,207
after neurology's gotten involved,
to look for some of the more subtle

584
00:29:31,207 --> 00:29:32,947
things that can cause abnormalities.

585
00:29:33,247 --> 00:29:37,602
But just keep in mind, the non-contrast
CT doesn't rule out everything bad.

586
00:29:37,822 --> 00:29:41,252
So you may have to go chase it with
other things especially if you're looking

587
00:29:41,252 --> 00:29:43,082
for increased intracranial pressure.

588
00:29:43,302 --> 00:29:47,262
Now if they're not having the generalized
tonic-clonic seizure, this is a good

589
00:29:47,262 --> 00:29:51,162
opportunity to pull out your ultrasound
and do a quick ocular ultrasound and

590
00:29:51,162 --> 00:29:54,792
look at their optic disc and get that
quick optic nerve measurement, and

591
00:29:54,792 --> 00:29:58,572
that can give you a, measurement that
can suggest increased intracranial

592
00:29:58,572 --> 00:30:03,052
pressure as an etiology and is a
quick, rapid bedside test to do.

593
00:30:03,082 --> 00:30:04,152
So, something to think about.

594
00:30:04,152 --> 00:30:09,162
And if you're worried about other
etiologies you can then get things like

595
00:30:09,402 --> 00:30:14,682
CT venograms, MR venograms in patients
who are hypercoagulable or pregnant or

596
00:30:14,872 --> 00:30:18,392
have a persistent headache, or if you do
the ultrasound and you see papilledema.

597
00:30:18,692 --> 00:30:21,822
So all of those things are possibilities.

598
00:30:21,822 --> 00:30:25,932
But by far, the initial study
that we're all obtaining is just

599
00:30:25,932 --> 00:30:27,492
a non-contrast CT of the brain.

600
00:30:28,192 --> 00:30:31,282
Then moving on to something
that may be necessary.

601
00:30:31,282 --> 00:30:32,482
And that's the lumbar puncture.

602
00:30:32,482 --> 00:30:36,712
So if you have an abnormal ultrasound
finding and you are considering

603
00:30:36,712 --> 00:30:41,132
increased intracranial pressure, then
that is one way to measure it directly.

604
00:30:41,392 --> 00:30:44,242
Obviously, again, very difficult
to do while they're still seizing.

605
00:30:44,242 --> 00:30:47,817
So this is kind of after you've
either terminated the seizure or

606
00:30:47,817 --> 00:30:51,507
intubated them and initiated a coma,
and then now you're able to have

607
00:30:51,507 --> 00:30:53,157
them be still for this procedure.

608
00:30:53,497 --> 00:30:56,317
It's also very helpful
to look for infections.

609
00:30:56,317 --> 00:31:00,221
It's helpful to look for pleocytosis,
evidence for increased protein

610
00:31:00,221 --> 00:31:03,711
and other things that can help you
down the differential diagnosis

611
00:31:03,711 --> 00:31:05,421
for causes for status epilepticus.

612
00:31:05,421 --> 00:31:08,361
So it's not just for pressure
and not just for infection.

613
00:31:09,061 --> 00:31:12,891
T.R. Eckler: Yeah, I think more
autoimmune, more neoplastic cases like,

614
00:31:12,891 --> 00:31:15,891
I think that's more and more of what
we're starting to see is that these

615
00:31:16,131 --> 00:31:19,251
cases that we can't find a cause,
the more we get into them, the more

616
00:31:19,251 --> 00:31:20,751
finding it's those kinds of things.

617
00:31:20,871 --> 00:31:24,021
And I think the more you can get an
LP on those patients, and the earlier

618
00:31:24,021 --> 00:31:26,991
you can get it, I think the more yield
you're gonna get and the faster the

619
00:31:26,991 --> 00:31:28,611
inpatient team's gonna get to the answer.

620
00:31:29,311 --> 00:31:31,381
Sam: And you don't even have to
know what tests you need to order.

621
00:31:31,411 --> 00:31:33,421
Just get the fluid and
have it sitting in the lab.

622
00:31:33,541 --> 00:31:36,611
You're gonna look for infection, and
then they'll add on a bunch of you

623
00:31:36,611 --> 00:31:39,751
know, antibodies and things that they're
looking for considering the differential

624
00:31:39,921 --> 00:31:42,391
T.R. Eckler: Fancy upstairs
tests is what I call 'em.

625
00:31:43,091 --> 00:31:43,541
Sam: Nice.

626
00:31:44,241 --> 00:31:46,041
And then there's the EEG.

627
00:31:46,251 --> 00:31:50,391
So again, it's very, very helpful
to get neurology involved early.

628
00:31:50,551 --> 00:31:54,091
If you have an EEG tech and the
ability to get these EEGs in the

629
00:31:54,091 --> 00:31:57,031
emergency department, it's very
helpful to get them contemporaneously

630
00:31:57,031 --> 00:31:58,501
with all the other stuff.

631
00:31:58,601 --> 00:32:02,481
It's exceedingly helpful in the
differential diagnosis and to

632
00:32:02,481 --> 00:32:03,861
determine if they're still seizing.

633
00:32:04,146 --> 00:32:06,516
You know, the ESSEP trial that
the authors mentioned was a

634
00:32:06,516 --> 00:32:10,566
randomized controlled trial, 475
patients in 58 different hospitals.

635
00:32:10,866 --> 00:32:15,826
48%, so only half of the patients,
actually had altered consciousness

636
00:32:15,946 --> 00:32:22,066
following status epilepticus and continued
to have non convulsive seizures on EEG.

637
00:32:22,066 --> 00:32:27,549
So, half of those still seizing, but
without any external signs of continued

638
00:32:27,549 --> 00:32:29,379
seizure, like you mentioned before.

639
00:32:29,569 --> 00:32:33,139
And so this can be particularly
challenging and this is a great tool

640
00:32:33,276 --> 00:32:34,776
for trying to detect that early.

641
00:32:35,176 --> 00:32:36,676
T.R. Eckler: This technology
is just advancing.

642
00:32:36,676 --> 00:32:39,816
I feel like we're gonna see more and
more interesting ways to like do seizure

643
00:32:39,816 --> 00:32:43,566
monitoring on people as it just gets
more micro and easier to use, you know?

644
00:32:44,266 --> 00:32:48,406
Sam: Yeah, and typically the EEG testing
we're doing in the ED is spot testing, or

645
00:32:48,406 --> 00:32:52,936
it's kinda a one time 30 to 60 minutes and
then it's done, but these patients really

646
00:32:52,936 --> 00:32:56,746
need continuous EEG monitoring, especially
if they're intubated and going to the ICU.

647
00:32:56,996 --> 00:33:00,296
And so that can be done with
traditional EEG equipment.

648
00:33:00,296 --> 00:33:01,526
It can be done with video.

649
00:33:01,656 --> 00:33:05,976
It can be done with some of the newer
AI technology that is also monitoring

650
00:33:05,976 --> 00:33:07,416
brainwaves and then alarming.

651
00:33:07,726 --> 00:33:09,196
So lots of different options.

652
00:33:09,196 --> 00:33:13,306
And there are even some smaller products
now for emergency departments that don't

653
00:33:13,306 --> 00:33:18,486
have EEG techs available where you can
do a spot EEG with just two or three

654
00:33:18,486 --> 00:33:20,416
electrodes and get a quick reading.

655
00:33:20,606 --> 00:33:21,716
They're not as accurate.

656
00:33:21,716 --> 00:33:24,626
They do have a lot of false positives,
so, you know, understanding all of

657
00:33:24,626 --> 00:33:25,976
that, the technology's getting better.

658
00:33:26,196 --> 00:33:29,346
But hopefully if you don't have
EEG where you are, you've got

659
00:33:29,346 --> 00:33:31,911
one of these devices you can at
least get an initial reading from.

660
00:33:32,611 --> 00:33:33,721
All right, let's talk about treatment.

661
00:33:33,751 --> 00:33:37,931
So there is, we touched on this already
with Midazolam, but there's a great

662
00:33:37,931 --> 00:33:42,761
table on page 10, medications for status
epilepticus, which gives you first line,

663
00:33:42,911 --> 00:33:45,401
second line, and third line agents.

664
00:33:45,591 --> 00:33:49,461
The first line agents are always
going to be the benzodiazepines.

665
00:33:49,501 --> 00:33:53,491
Rapid onset have very good
evidence for terminating seizures

666
00:33:53,681 --> 00:33:55,091
even in status epilepticus.

667
00:33:55,091 --> 00:33:57,231
And that's what you want to give first.

668
00:33:57,231 --> 00:34:01,311
You do have IV and IM available to
you with Lorazepam and midazolam.

669
00:34:01,731 --> 00:34:04,681
There are some parents with children
who seize at home who are still

670
00:34:04,681 --> 00:34:07,191
using the rectal diazepam as well.

671
00:34:07,461 --> 00:34:11,511
But Midazolam and Lorazepam both
have actually better efficacy.

672
00:34:11,511 --> 00:34:15,621
So if you have an IV or can give it
IM, that's still the preferred route.

673
00:34:16,321 --> 00:34:20,029
T.R. Eckler: There's a new product called
Valtoco that's basically nasal Valium,

674
00:34:20,029 --> 00:34:24,289
and I find that that's replacing a lot of
the rectal Valium that's out there now.

675
00:34:24,659 --> 00:34:27,629
I also would note that I think that drug
shortages are really affecting this.

676
00:34:28,036 --> 00:34:28,256
Sam: Mm.

677
00:34:28,294 --> 00:34:30,484
T.R. Eckler: Right now we don't
have any access to Lorazepam.

678
00:34:30,664 --> 00:34:33,964
So despite it being the first line
agent, it's not something that

679
00:34:33,964 --> 00:34:37,264
we have readily available in the
intravenous form in our hospital.

680
00:34:37,474 --> 00:34:41,914
So you've gotta be ready to adjust
to hospital supplies, drug shortages.

681
00:34:42,064 --> 00:34:45,694
So I think that's why this table is so
valuable is because you need to be ready

682
00:34:45,694 --> 00:34:50,014
to use what agents you have and then be
ready to escalate, not just to like one

683
00:34:50,014 --> 00:34:52,864
of the things in the next group, but
any of the things that are available,

684
00:34:52,984 --> 00:34:55,979
depending on what you have and what the
patient actually responds to in the past.

685
00:34:56,566 --> 00:34:56,896
Sam: Yeah.

686
00:34:57,596 --> 00:34:57,806
Yeah.

687
00:34:57,806 --> 00:35:01,096
And on this topic, it's also important
to make sure you're giving the right

688
00:35:01,126 --> 00:35:03,796
dose based on the person's weight.

689
00:35:03,826 --> 00:35:07,906
So, you know, adult doses of lorazepam
are maximum four milligrams per dose,

690
00:35:07,906 --> 00:35:10,156
but it's 0.1 milligrams per kilogram.

691
00:35:10,546 --> 00:35:14,746
If you're dosing midazolam especially
if you're giving it IM in an adult,

692
00:35:14,746 --> 00:35:18,446
it's 0.2 milligrams per kilogram
with a maximum of 10 milligrams.

693
00:35:18,446 --> 00:35:23,406
So underdosing is a frequent problem
that results in recurrent seizures

694
00:35:23,406 --> 00:35:25,326
and in continued status epilepticus.

695
00:35:25,326 --> 00:35:28,776
So don't be afraid to give
the full dose and if they have

696
00:35:29,106 --> 00:35:32,706
somnolence and respiratory
failure, you deal with all that.

697
00:35:32,706 --> 00:35:35,016
You have the tools to
work with all of that.

698
00:35:35,016 --> 00:35:37,626
But priority number one is
terminate the seizure and make

699
00:35:37,626 --> 00:35:38,796
sure you're giving the right dose.

700
00:35:39,349 --> 00:35:42,379
T.R. Eckler: Stopping a seizure,
but arriving in intubation is a win

701
00:35:42,379 --> 00:35:44,029
so long as their glucose is normal.

702
00:35:44,059 --> 00:35:46,639
That's my feeling about
status patients like this.

703
00:35:46,821 --> 00:35:47,451
Sam: That's perfect.

704
00:35:47,571 --> 00:35:48,446
That is a perfect summary.

705
00:35:49,146 --> 00:35:52,316
Second line agents include
things like levetiracetam,

706
00:35:52,316 --> 00:35:58,071
valproate sodium, fosphenytoin,
phenobarbital, and lacosamide.

707
00:35:58,071 --> 00:36:03,901
So all of these medications are in the
second line therapy arena, and you're

708
00:36:03,901 --> 00:36:07,561
gonna give your benzos and you're
probably gonna give your benzos again

709
00:36:07,561 --> 00:36:09,271
before you reach for one of these things.

710
00:36:09,271 --> 00:36:12,421
So it's like, give a dose of
benzos, wait a minute or two, give

711
00:36:12,421 --> 00:36:15,841
another dose of benzos, and then
reach for one of these agents.

712
00:36:16,111 --> 00:36:18,781
And this is where it becomes helpful
to know what they're taking at home,

713
00:36:18,811 --> 00:36:21,061
because it may or may not be effective.

714
00:36:21,061 --> 00:36:23,671
If they haven't been on it for a while,
you may have to give a loading dose.

715
00:36:23,861 --> 00:36:27,971
Levetiracetam has always been my favorite
just because of the ease of dosing and

716
00:36:27,971 --> 00:36:32,114
the loading and I think our neurology
colleagues quickly became fans of it as

717
00:36:32,114 --> 00:36:36,104
well because of its ability to be loaded
in people with renal failure and with

718
00:36:36,104 --> 00:36:37,904
all kinds of other metabolic issues.

719
00:36:37,904 --> 00:36:40,364
It's like just give the loading dose and
we'll worry about the next one later.

720
00:36:40,814 --> 00:36:41,924
But there are others.

721
00:36:41,984 --> 00:36:46,199
So keep in mind there are four
others to choose from on the

722
00:36:46,199 --> 00:36:48,059
list besides levetiracetam.

723
00:36:48,089 --> 00:36:51,299
And like you mentioned before, just know
what you have in your pyxis, know what you

724
00:36:51,299 --> 00:36:55,899
have in your pharmacy, and consider how
long it's gonna take to give it as well.

725
00:36:56,599 --> 00:36:59,779
T.R. Eckler: Levetiracetam for a hundred
kilogram person, you can give it in

726
00:36:59,779 --> 00:37:04,219
about nine minutes, if you're kind of
going at the max rate of about five mgs

727
00:37:04,219 --> 00:37:07,589
per kilo per minute, but then if you're
looking at the other drugs on there,

728
00:37:07,589 --> 00:37:09,449
it's gonna take significantly longer.

729
00:37:09,599 --> 00:37:13,169
And I think that then adjusts, if
you know you start that load, but the

730
00:37:13,169 --> 00:37:16,794
patient starts seizing, you need to be
ready to move to your third line agents.

731
00:37:16,944 --> 00:37:19,764
You know, maybe think about a dose
of ketamine, or you're going to full

732
00:37:19,764 --> 00:37:21,654
on intubation and the other drugs.

733
00:37:21,834 --> 00:37:25,224
But I think you need to know how long it's
gonna take to get that medicine into the

734
00:37:25,224 --> 00:37:28,764
patient, and then be ready with how your
plan responds according to what you've

735
00:37:28,764 --> 00:37:30,084
got available and what you're gonna use.

736
00:37:30,784 --> 00:37:34,714
Sam: And keep in mind, the maximum
dose is probably way higher

737
00:37:34,804 --> 00:37:35,974
than anything you've ever given.

738
00:37:35,974 --> 00:37:39,744
You know, levetiracetam's a great
one, max dose four and a half grams.

739
00:37:39,927 --> 00:37:43,477
Can't say I've ever dosed anybody with
that much but your neurology colleague

740
00:37:43,477 --> 00:37:47,107
may ask you to do so for somebody
headed to the ICU with continued non

741
00:37:47,107 --> 00:37:51,077
convulsive status on EEG, you're gonna
keep pushing that higher and higher.

742
00:37:51,297 --> 00:37:55,287
So just be aware that the max dose is
much higher than the routine dose we give.

743
00:37:55,987 --> 00:37:56,287
All right.

744
00:37:56,287 --> 00:37:58,267
And then third line agents.

745
00:37:58,267 --> 00:38:03,217
So this is the person who's now about
to be intubated and put on a ventilator.

746
00:38:03,437 --> 00:38:06,257
And we're looking for
continuous infusions, right?

747
00:38:06,257 --> 00:38:10,577
So Midazolam still in this list,
right, has shown good efficacy.

748
00:38:10,787 --> 00:38:14,447
There is good published data for
midazolam versus propofol, and they're

749
00:38:14,447 --> 00:38:16,797
about equal for continuous infusion.

750
00:38:16,797 --> 00:38:19,617
Now, whether or not you have
midazolam available and that much

751
00:38:19,617 --> 00:38:25,127
available is another question, but
just know that can be a method for

752
00:38:25,147 --> 00:38:26,887
controlling continuous seizures.

753
00:38:27,587 --> 00:38:31,367
Propofol certainly always one of my
favorites, but comes with the propofol

754
00:38:31,367 --> 00:38:35,537
infusion syndrome as a possible side
effects  and lots of derangements and

755
00:38:35,537 --> 00:38:37,097
increased morbidity and mortality.

756
00:38:37,097 --> 00:38:40,677
So uh, your colleagues in the
ICU may rapidly change them to

757
00:38:40,677 --> 00:38:42,177
something else, and that's okay.

758
00:38:42,627 --> 00:38:47,407
Pentobarbital is something I have
personally never given, but may

759
00:38:47,407 --> 00:38:49,297
be available in your pharmacy.

760
00:38:49,517 --> 00:38:53,157
Thiopental is also something
I've never had to give, but may

761
00:38:53,157 --> 00:38:54,597
be available in your pharmacy.

762
00:38:54,597 --> 00:38:55,377
And lastly, ketamine.

763
00:38:56,411 --> 00:39:01,111
So ketamine, interestingly, a little
asterisk there, was recommended by the

764
00:39:01,111 --> 00:39:07,441
authors as something you might try before
you reach for a continuous infusion

765
00:39:07,441 --> 00:39:12,651
and intubate somebody as a single dose
because there is a growing number of case

766
00:39:12,651 --> 00:39:16,911
reports of people who have terminated
seizures with a dose of ketamine.

767
00:39:17,191 --> 00:39:19,861
Not as a continuous infusion,
but just a dose of ketamine

768
00:39:20,081 --> 00:39:22,031
before progressing to intubation.

769
00:39:22,031 --> 00:39:24,431
And you might be able to keep
somebody off a ventilator.

770
00:39:25,131 --> 00:39:26,756
T.R. Eckler: I think especially
as you're getting ready to

771
00:39:26,756 --> 00:39:28,316
start infusion, it takes time.

772
00:39:28,496 --> 00:39:32,156
I think you've got that moment there
where if they're still seizing or

773
00:39:32,192 --> 00:39:35,302
showing you signs of non convulsive
status where they're not coming around.

774
00:39:35,602 --> 00:39:38,252
I think that there's room for that
dose of ketamine, while you're

775
00:39:38,272 --> 00:39:39,442
getting set up for everything else.

776
00:39:40,087 --> 00:39:43,987
I also think to your point, I reach
more for midazolam in children and

777
00:39:43,987 --> 00:39:46,597
I reach more for propofol in adults.

778
00:39:46,817 --> 00:39:49,367
But I think it depends on kind
of the patient's history, what

779
00:39:49,367 --> 00:39:50,657
their blood pressure looks like.

780
00:39:50,817 --> 00:39:54,101
I think there's a lot of factors that
go into this and I think that all of

781
00:39:54,101 --> 00:39:57,266
those things are now always part of my
evolving approach to these patients.

782
00:39:57,966 --> 00:40:01,401
Sam: And if you're wondering, you
know, about the clinical efficacy for

783
00:40:01,401 --> 00:40:04,731
each of these medications, especially
like second and third line agents, the

784
00:40:04,731 --> 00:40:09,141
authors did a good job of saying, yes,
there is published data for all of these

785
00:40:09,161 --> 00:40:10,511
and the efficacy is about the same.

786
00:40:10,511 --> 00:40:13,791
So you know, levetiracetam doesn't
work necessarily any better than

787
00:40:13,791 --> 00:40:16,341
fosphenytoin, and doesn't necessarily
work any better than valproate

788
00:40:16,691 --> 00:40:19,647
and propofol doesn't necessarily
work any better than midazolam.

789
00:40:19,747 --> 00:40:22,347
It's more what you have and
what you can get quickly.

790
00:40:23,047 --> 00:40:23,377
Okay.

791
00:40:23,377 --> 00:40:27,167
And then these are the patients who
are going to the ICU and considered

792
00:40:27,347 --> 00:40:30,167
super refractory status epilepticus.

793
00:40:30,167 --> 00:40:33,287
So I think that's gonna be the highest
category where they just continue

794
00:40:33,287 --> 00:40:34,667
to seize no matter what you do.

795
00:40:34,917 --> 00:40:37,887
And I think that at this point,
if you haven't already gotten your

796
00:40:37,887 --> 00:40:40,737
neurology colleagues involved,
it's going to be whatever agents

797
00:40:40,737 --> 00:40:43,857
they prefer on top of whatever
continuous infusion you've provided.

798
00:40:44,557 --> 00:40:47,522
T.R. Eckler: To the final boss
of the NORSE seizure battle

799
00:40:47,522 --> 00:40:48,692
game that you're playing.

800
00:40:48,882 --> 00:40:51,822
This is like the tough boss that
you've gotta use all your weapons on.

801
00:40:52,069 --> 00:40:52,459
Sam: That's right.

802
00:40:53,039 --> 00:40:54,109
The big boss at the end of the video game

803
00:40:54,192 --> 00:40:55,482
T.R. Eckler: The big boss at the end.

804
00:40:56,112 --> 00:40:58,092
Sam: And then some special
populations, right?

805
00:40:58,092 --> 00:41:02,232
So there are going to be some cases
which are handled differently.

806
00:41:02,362 --> 00:41:04,912
Pregnancy is certainly one of them.

807
00:41:04,912 --> 00:41:08,692
So if your patient is pregnant
and presenting with continuous

808
00:41:08,692 --> 00:41:13,192
seizures or status epilepticus, then
eclampsia needs to be at the top

809
00:41:13,192 --> 00:41:16,402
of the list, and the first agent
you're reaching for is magnesium.

810
00:41:16,652 --> 00:41:21,902
And that is a giant whopping dose of four
to six grams IV over 15 to 20 minutes.

811
00:41:21,902 --> 00:41:25,982
So it's a very rapid infusion of
magnesium, followed by a continuous

812
00:41:25,982 --> 00:41:28,082
infusion of one to two grams per hour.

813
00:41:28,302 --> 00:41:32,917
And then you're getting your OB colleagues
involved and kind of discussing maybe

814
00:41:32,917 --> 00:41:35,167
delivering of the baby at this point.

815
00:41:35,387 --> 00:41:40,330
So that's a very, very different pathway
that you need to identify immediately

816
00:41:40,580 --> 00:41:42,590
before you are giving other substances.

817
00:41:42,590 --> 00:41:47,115
Now you can still give lorazepam,
you can still give fosphenytoin,

818
00:41:47,235 --> 00:41:49,305
you can still give levetiracetam.

819
00:41:49,435 --> 00:41:52,825
Some of them don't have the greatest
side effect profile in pregnancy.

820
00:41:53,045 --> 00:41:57,345
But if they get the mag and they
continue to seize , you're not out of

821
00:41:57,375 --> 00:42:00,975
medication treatment at that point, you
can still give these other agents in

822
00:42:00,975 --> 00:42:05,255
consultation with your neurologist and
your OB because the longer the mother

823
00:42:05,255 --> 00:42:09,005
is seizing, the longer her brain is at
risk and the longer the fetus is at risk.

824
00:42:09,005 --> 00:42:11,435
So you're saving both
lives in this scenario.

825
00:42:12,135 --> 00:42:16,495
T.R. Eckler: You did put a little caution
on fosphenytoin and valproic acid . So

826
00:42:16,495 --> 00:42:20,562
it seems like levetiracetam, which you're
so much better at saying than I am,  is

827
00:42:20,562 --> 00:42:24,582
more of the kind of recommended third line
after your, magnesium and your benzos.

828
00:42:24,822 --> 00:42:27,942
But as I think you said, I think
you give those three things while

829
00:42:27,942 --> 00:42:31,842
you're punching the number for OBGYN
and getting them to the bedside.

830
00:42:31,872 --> 00:42:34,782
'Cause delivery is really the thing
that's gonna save this duo here.

831
00:42:35,482 --> 00:42:35,752
Sam: Yeah.

832
00:42:35,752 --> 00:42:38,842
And you know, in pregnancy, it's not
just eclampsia, but it's things like

833
00:42:38,992 --> 00:42:42,922
posterior reversible encephalopathy
syndrome, reversible cerebral

834
00:42:42,962 --> 00:42:48,022
vasoconstriction syndrome and cortical
venous thrombosis, all of these things can

835
00:42:48,022 --> 00:42:50,532
cause seizures in the pregnant patient.

836
00:42:50,532 --> 00:42:55,407
So the differential is different and it
is treated differently in most cases.

837
00:42:55,597 --> 00:42:59,567
Just don't forget the mag and
the mag and the mag because

838
00:42:59,567 --> 00:43:00,797
that's the treatment of choice.

839
00:43:01,497 --> 00:43:02,156
There is substance induced status

840
00:43:04,175 --> 00:43:08,075
epilepticus, so somewhere between
nine and 10% of status epilepticus

841
00:43:08,075 --> 00:43:10,215
cases are substance induced.

842
00:43:10,480 --> 00:43:15,610
And these are things like antidepressants,
stimulants, antihistamines,

843
00:43:15,610 --> 00:43:19,610
tramadol, isoniazid, and they
can have some specific therapies.

844
00:43:19,610 --> 00:43:23,973
So if you know that they're using
isoniazid and they're toxic from it, then

845
00:43:24,243 --> 00:43:26,233
pyridoxine is the treatment of choice.

846
00:43:26,583 --> 00:43:29,773
Phenytoin interestingly,
not as highly recommended in

847
00:43:29,773 --> 00:43:31,153
drug-induced status epilepticus.

848
00:43:31,153 --> 00:43:32,623
Doesn't tend to do as well.

849
00:43:32,783 --> 00:43:34,403
But your other choices are pretty good.

850
00:43:34,403 --> 00:43:35,873
And your, you know, your first drug?

851
00:43:35,963 --> 00:43:38,768
Well, my first drug levetiracetam
is the one that seems to

852
00:43:38,768 --> 00:43:40,328
work okay in these patients.

853
00:43:40,328 --> 00:43:44,178
So just know that there's a significant
number of patients and drug toxicity

854
00:43:44,178 --> 00:43:46,038
is definitely in the differential.

855
00:43:46,388 --> 00:43:49,928
T.R. Eckler: Your catch for the isoniazid
patient is a tuberculosis patient that

856
00:43:49,928 --> 00:43:53,258
tried to kill themselves and took too
much of their tuberculosis medicine.

857
00:43:53,408 --> 00:43:58,208
And I think the classic teaching on this
is that if you need B6 to try to stop

858
00:43:58,208 --> 00:44:01,878
these people's seizures, you need all
the B6 in your hospital and all the B6

859
00:44:01,898 --> 00:44:03,368
in a bunch of surrounding hospitals.

860
00:44:03,518 --> 00:44:07,003
So once you've made this diagnosis, it's
also one where you need to make that

861
00:44:07,003 --> 00:44:10,463
next step to talk to your pharmacy and
say, Hey, we're gonna need a lot of B6.

862
00:44:10,483 --> 00:44:11,473
You know, this is what I've got.

863
00:44:11,713 --> 00:44:13,393
Figure out how much we're
gonna need and then figure out

864
00:44:13,393 --> 00:44:14,468
where we're gonna get it from.

865
00:44:14,558 --> 00:44:15,458
And let me know.

866
00:44:15,680 --> 00:44:18,210
Sam: Yeah, and you're
gonna need some isolation.

867
00:44:18,910 --> 00:44:19,570
T.R. Eckler: Well, it depends.

868
00:44:19,582 --> 00:44:22,012
If it's not really active TB, you
just, you can just fix the seizures.

869
00:44:22,012 --> 00:44:23,097
But, we'll, we'll get to that part.

870
00:44:23,797 --> 00:44:26,437
I'm sure they came in with full PPE.

871
00:44:26,564 --> 00:44:27,684
Well contained.

872
00:44:27,844 --> 00:44:29,107
Everything taken care of.

873
00:44:29,737 --> 00:44:32,587
Sam: And then there was a great
section there on pediatric patients,

874
00:44:32,587 --> 00:44:35,977
which actually I'm not going to dive
into, but I will encourage you to

875
00:44:35,977 --> 00:44:39,727
go back a couple of months on this
podcast and listen to the episode we

876
00:44:39,727 --> 00:44:41,677
did on pediatric status epilepticus.

877
00:44:41,907 --> 00:44:45,847
It is a little different but overall
I think the management points

878
00:44:45,847 --> 00:44:47,407
were, were very, very similar.

879
00:44:47,567 --> 00:44:50,397
You stop the seizure, stop it
early and make sure you're aware

880
00:44:50,397 --> 00:44:53,617
of what medications you have and
what exposures the patient has had.

881
00:44:54,317 --> 00:44:57,437
T.R. Eckler: Here's my annual plug for the
wonderful PD stat app, so that if you have

882
00:44:57,437 --> 00:45:01,817
a kid that's sick with anything, you can
use the PD stat app to base your doses for

883
00:45:01,817 --> 00:45:05,297
their medications on their Broselow Tape,
or their age or their weight, whatever

884
00:45:05,297 --> 00:45:08,417
you've got, the most accurate measurement
you have for their age and size.

885
00:45:08,732 --> 00:45:11,612
Then that will give you every drug
you need and everything you need

886
00:45:11,612 --> 00:45:12,932
to resuscitate them right there.

887
00:45:13,112 --> 00:45:17,222
It makes the cognitive load decrease
dramatically so you can just focus

888
00:45:17,462 --> 00:45:20,742
on getting that little bugger
healthy and back to normal again.

889
00:45:20,859 --> 00:45:21,149
Sam: Yeah.

890
00:45:21,532 --> 00:45:25,912
Before we end, I wanna put in a quick plug
for the risk management pitfall section

891
00:45:25,912 --> 00:45:27,922
in every single one of these issues.

892
00:45:27,922 --> 00:45:29,032
They're fantastic.

893
00:45:29,102 --> 00:45:31,562
We're gonna go through a couple
today for the status epilepticus.

894
00:45:31,562 --> 00:45:34,322
The first one, the patient isn't
having any abnormal movements,

895
00:45:34,322 --> 00:45:35,672
so he's not seizing anymore.

896
00:45:35,792 --> 00:45:38,382
I think we drove that
point home pretty well.

897
00:45:38,472 --> 00:45:43,002
That non convulsive status epilepticus is
a thing and you should be very suspicious.

898
00:45:43,702 --> 00:45:43,942
T.R. Eckler: Turn.

899
00:45:44,002 --> 00:45:45,292
Turn that on its head a little bit.

900
00:45:45,292 --> 00:45:47,842
If the patient isn't moving,
you should be a little worried.

901
00:45:47,877 --> 00:45:49,007
They should start moving.

902
00:45:49,344 --> 00:45:49,794
Sam: Yeah,

903
00:45:50,047 --> 00:45:50,887
T.R. Eckler: Movement, good.

904
00:45:51,387 --> 00:45:52,672
Too much movement, bad.

905
00:45:52,672 --> 00:45:54,532
No movement, also bad.

906
00:45:54,534 --> 00:45:55,164
Sam: Also bad.

907
00:45:55,164 --> 00:45:56,184
That's right, that's right.

908
00:45:56,184 --> 00:45:57,694
There is a sweet spot
somewhere in the middle

909
00:45:57,767 --> 00:45:57,987
T.R. Eckler: Yes.

910
00:45:58,564 --> 00:46:03,094
Sam: Number two, we gave two milligrams
of lorazepam so the seizures should stop.

911
00:46:03,094 --> 00:46:06,604
The point here being that it's not
a standard dose, it's a weight-based

912
00:46:06,604 --> 00:46:10,774
dose, and you wanna give the correct
amount based on the patient's weight,

913
00:46:10,774 --> 00:46:12,604
which could be up to four milligrams.

914
00:46:12,934 --> 00:46:16,569
And repeat that once with a maximum
dose of eight milligrams before

915
00:46:16,569 --> 00:46:17,679
you go on to your next agent.

916
00:46:17,679 --> 00:46:20,529
So if you gave them two and it didn't
work and you gave them two more,

917
00:46:20,529 --> 00:46:24,129
you're only halfway there before
you should be giving anything else.

918
00:46:24,159 --> 00:46:25,304
So make sure you get the right amount.

919
00:46:26,004 --> 00:46:31,104
The point of care EEG showed no
seizures, so we didn't need formal EEG

920
00:46:31,104 --> 00:46:35,484
monitoring, and that's just a reminder
that this particular product is good

921
00:46:35,484 --> 00:46:40,204
to have but doesn't yet have the
sensitivity and specificity needed to

922
00:46:40,204 --> 00:46:42,304
completely exclude continued seizures.

923
00:46:42,304 --> 00:46:46,779
So you still need a dedicated
EEG for the non convulsive cases.

924
00:46:47,479 --> 00:46:49,909
T.R. Eckler: So you've just given
them a ton of drugs to tamp down

925
00:46:49,909 --> 00:46:51,139
their ability to have a seizure.

926
00:46:51,379 --> 00:46:55,219
So you need to then watch them as those
drugs fade away to see what develops.

927
00:46:55,339 --> 00:46:56,869
And that's what they're
getting admitted for.

928
00:46:57,140 --> 00:46:57,320
Sam: Yep.

929
00:46:57,710 --> 00:46:59,630
And if you can't do that at
your facility, that's okay.

930
00:46:59,690 --> 00:47:02,040
You gotta send them somewhere
where they can Right.

931
00:47:02,390 --> 00:47:02,910
Transfer them.

932
00:47:03,680 --> 00:47:07,760
The patient has a history of epilepsy, so
the seizure must be due to non-adherence.

933
00:47:07,760 --> 00:47:09,380
No further workup is required.

934
00:47:09,590 --> 00:47:13,610
I think your example of the levetiracetam
level you did on that patient,

935
00:47:13,700 --> 00:47:15,050
it was a, was a great one, right?

936
00:47:15,050 --> 00:47:17,330
So she was compliant and
yet still having seizures.

937
00:47:17,330 --> 00:47:17,960
It happens.

938
00:47:18,170 --> 00:47:19,130
Something to keep in mind.

939
00:47:19,644 --> 00:47:22,374
T.R. Eckler: I had an alcoholic once
in rural Colorado that was known to

940
00:47:22,374 --> 00:47:25,104
go into withdrawal seizures, and I
was used to giving him a dose or two

941
00:47:25,104 --> 00:47:26,514
and he would stop and we'd be fine.

942
00:47:26,634 --> 00:47:30,234
And I, one time I just couldn't get him to
stop and I had to intubate him and I felt

943
00:47:30,234 --> 00:47:32,334
like I just had not managed it correctly.

944
00:47:32,454 --> 00:47:34,434
And then I took him to CT and
he had a giant head bleed.

945
00:47:34,870 --> 00:47:35,090
Sam: Hmm.

946
00:47:36,274 --> 00:47:38,444
T.R. Eckler: That's, it's one of those
things where, if the patient has a

947
00:47:38,444 --> 00:47:41,444
history of seizures and you're not
getting them to come around , it's

948
00:47:41,474 --> 00:47:42,494
'cause there's something else there.

949
00:47:42,494 --> 00:47:44,534
So keep working 'em up,
keep working the problem.

950
00:47:44,835 --> 00:47:45,495
Sam: Great case.

951
00:47:45,495 --> 00:47:46,155
Great case.

952
00:47:46,855 --> 00:47:50,425
The patient has renal failure, so I should
reduce the loading dose of levetiracetam.

953
00:47:50,515 --> 00:47:52,805
Again, that loading dose
is the same upfront.

954
00:47:52,805 --> 00:47:55,565
Now your follow-up doses may be
different and the schedule may be

955
00:47:55,565 --> 00:47:57,485
different, but the load is the same.

956
00:47:58,185 --> 00:48:01,035
We successfully treated the
seizures so the patient does

957
00:48:01,035 --> 00:48:03,585
not need a higher level of care.

958
00:48:03,675 --> 00:48:07,985
Interesting point here that if a patient
is no longer seizing and they don't meet

959
00:48:07,985 --> 00:48:12,645
the critical care unit requirements you
still need admission to an inpatient

960
00:48:12,645 --> 00:48:16,643
neurology service or a place where that's
available to get the rest of the workup.

961
00:48:16,833 --> 00:48:18,543
And so terminating the seizures, great.

962
00:48:18,663 --> 00:48:22,113
That gets you most of the way there, but
then you gotta figure out why it happened.

963
00:48:22,813 --> 00:48:24,743
T.R. Eckler: Again, these are
patients with status epilepticus.

964
00:48:24,763 --> 00:48:27,703
It's not just patients with just
seizures that come back to baseline.

965
00:48:27,943 --> 00:48:30,193
The patients with status who
aren't returning their baseline,

966
00:48:30,433 --> 00:48:33,103
who've had multiple seizures
required multiple medications.

967
00:48:33,343 --> 00:48:37,123
There needs to be a higher threshold for
these patients than just your usual had

968
00:48:37,123 --> 00:48:38,833
one seizure and now is normal patient.

969
00:48:39,509 --> 00:48:43,386
Sam: The patient's seizures stopped
after I administered benzodiazepines,

970
00:48:43,386 --> 00:48:45,786
so they don't need any more medication.

971
00:48:46,266 --> 00:48:51,036
And the point here being that great
you have terminated their seizure.

972
00:48:51,256 --> 00:48:53,866
But that medication is very
temporary, very short acting.

973
00:48:54,056 --> 00:48:58,256
And they need one of those second line
agents to provide consistent control and

974
00:48:58,256 --> 00:49:00,296
not allow any more breakthrough seizures.

975
00:49:00,546 --> 00:49:02,706
So just terminating it is not enough.

976
00:49:03,406 --> 00:49:06,466
And lastly, the patient saturations
are in the low nineties, so

977
00:49:06,466 --> 00:49:09,316
I'll give a lower dose of
benzodiazepines to protect the airway.

978
00:49:10,016 --> 00:49:13,856
And this really just drives the point
of you're gonna stop the seizure first

979
00:49:14,036 --> 00:49:18,776
and deal with the respiratory depression
some other way by controlling the airway.

980
00:49:19,076 --> 00:49:23,826
Don't worry about respiratory suppression
because if it happens, you're gonna

981
00:49:23,826 --> 00:49:25,566
need to intubate this patient anyway.

982
00:49:25,886 --> 00:49:28,166
Stop the seizure, don't let it continue.

983
00:49:28,866 --> 00:49:31,396
T.R. Eckler: And their receptors
are downregulated, so you need

984
00:49:31,396 --> 00:49:33,136
more benzo to break through that.

985
00:49:33,136 --> 00:49:34,941
So I liked their argument.

986
00:49:34,941 --> 00:49:35,781
I thought it was a good one.

987
00:49:36,068 --> 00:49:36,278
Sam: Yep.

988
00:49:36,398 --> 00:49:39,008
More benzos, more quickly,
as fast as you can.

989
00:49:39,338 --> 00:49:41,828
And as always, the last
page has a clinical pathway.

990
00:49:41,828 --> 00:49:45,488
So it includes the medications,
the dosing, the first, the second

991
00:49:45,488 --> 00:49:48,488
line, the third line, when to
give 'em, do the seizures persist,

992
00:49:48,488 --> 00:49:49,493
how to give 'em, et cetera.

993
00:49:49,843 --> 00:49:51,403
It's a great little pathway to have.

994
00:49:51,403 --> 00:49:55,613
So if you don't want just a table of meds
and you want a step-by-step progression,

995
00:49:55,763 --> 00:49:59,603
it's a great one to have in your back
pocket for how to treat these patients.

996
00:49:59,783 --> 00:50:05,423
They are very anxiety provoking patients
because you want to stop the seizure and

997
00:50:05,423 --> 00:50:09,863
you don't kind of get to relax and pause
until you stopped the overt seizure.

998
00:50:10,113 --> 00:50:14,233
So having a clinical pathway in your
back pocket is exceptionally helpful.

999
00:50:14,233 --> 00:50:17,444
And offloads some of that
brain activity of your own.

1000
00:50:18,144 --> 00:50:21,924
All right, ladies and gentlemen,
that's it for the September 2025 issue

1001
00:50:21,924 --> 00:50:26,184
of Emergency Medicine Practice on
status epilepticus in adult patients.

1002
00:50:26,184 --> 00:50:27,234
Thanks again to the authors.

1003
00:50:27,264 --> 00:50:31,584
Fantastic article, great summaries,
great tables, and an excellent pathway.

1004
00:50:32,064 --> 00:50:34,674
And as always, I'm Sam Ashoo.

1005
00:50:34,869 --> 00:50:36,979
T.R. Eckler: TR Eckler, good
luck with those super Vikings.

1006
00:50:37,679 --> 00:50:38,349
Sam: The Norse.

1007
00:50:38,839 --> 00:50:39,729
The Norse.

1008
00:50:40,099 --> 00:50:41,119
My nemesis.

1009
00:50:41,819 --> 00:50:42,839
All right, thanks everybody.

1010
00:50:42,839 --> 00:50:43,649
See you next time.

1011
00:50:44,435 --> 00:50:46,255
And that's a wrap for
this month's episode.

1012
00:50:46,295 --> 00:50:48,875
I hope you found it
educational and informative.

1013
00:50:49,075 --> 00:50:53,935
Don't forget to go to ebmedicine.net
to read the article and claim your CME.

1014
00:50:54,105 --> 00:50:57,295
And of course, check out all three
of the journals and the multitude of

1015
00:50:57,295 --> 00:51:01,655
resources available to you, both for
emergency medicine, pediatric emergency

1016
00:51:01,655 --> 00:51:03,925
medicine, and evidence based urgent care.

1017
00:51:04,235 --> 00:51:06,205
Until next time, everyone be safe.