LAS VEGAS – The treatment window for generalized, convulsive status epilepticus has been compressed in recent years, something that’s important for hospitalists to know, according to Dr. Andrew Josephson, medical director of inpatient neurology at the University of California, San Francisco.
"We’ve figured out that, for every minute that goes by, brain cells are dying and the seizure is becoming more resistant to treatment," he said at the annual meeting of the Society of Hospital Medicine.
Previously, general anesthetics didn’t come into play for maybe an hour or more. "That’s not how we do it nowadays. If a spell goes on for longer than 2 minutes, that’s status epilepticus and should be treated as such," he said.
Dr. Andrew Josephson
Lorazepam 2 mg IV comes first, every 2 minutes "until you’re worried about their airway" – generally after 4-8 doses. If lorazepam doses don’t work, patients are "loaded with IV fosphenytoin," not phenytoin, which is limb threatening if it infiltrates from the peripheral intravenous line. The dose of fosphenytoin is 18-20 mg/kg; a gram is insufficient in most adults, Dr. Josephson said.
Fosphenytoin takes about 10 minutes to run in. If patients are still seizing, "we generally go right to intubation, putting the patient in a suppressive state with general anesthetics. The things that we use are IV midazolam or IV propofol," he said.
"Keep in mind, we generally paralyze someone to intubate them, so they will stop shaking. That does not mean they have stopped seizing. So at this point, it’s extremely important that EEGs are taken when the patient is under general anesthesia," he said.
Follow-up in the hospital depends on whether it’s the patient’s first seizure or if he or she is a known epileptic.
Most first-time seizures in adults have an obvious explanation. Drugs and alcohol are high on the differential, along with meningitis/encephalitis. If the attack started focally, the patient has a brain tumor until proven otherwise. Low glucose also could be to blame, or low sodium, low magnesium, or low or high calcium.
Breakthrough seizures in known epileptics generally mean that something’s wrong with their antiepileptic medications – either they aren’t taking them or a new drug is interfering with them – or that they have a urinary tract infection, pneumonia, or some other systemic infection, and not necessarily a CNS infection.
Intramuscular midazolam has been in the news recently after it was found in a trial that 10 mg delivered by paramedics to the thigh by auto-injector works at least as well as intravenous lorazepam for status epilepticus (N. Engl. J. Med. 2012;366:591-600). Approval might come in 2014, and when it does the auto-injector is likely to "become the standard of care and benzodiazepine of choice for status epilepticus outside of the hospital and probably inside the hospital" since it’s far less cumbersome than fumbling with intravenous lines in the middle of a neurologic emergency, Dr. Josephson said.
Dr. Josephson has no relevant disclosures.