Status Epilepticus in the ICU – Pouya Ameli, MD

a nurse is caring for a client who has a history of status epilepticus
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hey guys my name is pom Lee and Im one of the neurocritical care fellows Im gonna be talking to you today about status epilepticus so before we can talk about status first we need to talk about whats the seizure and there are really two ways to answer this question right the first one is the pathophysiology of a seizure is basically just abnormal electrical activity in the brain and so to illustrate this kind of what happens I want everybody to raise their right hand up in the air I want you to move your index finger like so now imagine that the neurons controlling your index finger suddenly gain the ability to control the surrounding cortex such that your entire hand started to flex then your entire arm and then your other arm and then it basically spreads from there and thats basically what happens during a seizure thats what we worry about in patients with epilepsy clinically the most common thing that people think about is rhythmic movements and the way I know this is because every time somebody calls me for a consult theyre always like oh I swear their arm was moving rhythmically dont worry Im gonna come see your patient but I want you to know that seizures are actually a lot more than the symptoms of a seizure really just reflect the part of

the brain thats seizing so if its in the frontal lobe it could be something as simple as eye movement abnormalities if its in the temporal lobe it could be a fascia or mutism if its in the occipital lobe it could be weird kaleidoscope like visual phenomenon so knowing that who among us can have a seizure the correct answer is everybody right you can have a seizure you can have a seizure you can have a seizure seriously if I put your body under enough stress every person in this room will cease and we know that because we use ECT to treat patients with psychiatric disease electroconvulsive therapy and we know that different patients require different amounts of stimulus to induce their brain to have a seizure so from that perspective epilepsy is really just having a seizure threshold low enough that you actually cross it regularly and 10% of us will cross our seizure threshold at some point in our life so what lowers your seizure threshold its a lot of things that you guys are familiar with the most common are drugs antidepressants anti reflux and antibiotics being the usual culprits metabolic disturbances such as electrolyte abnormalities hypo and hyper glycaemia malnutrition and of course sleep deprivation the beloved queue on our neuro check and we cant forget about acute illness right anytime you stress out the

bodys coping mechanisms youre going to open the door for bad things to happen so knowing that our patients are at very high risk of having seizure I want to emphasize to you that early treatment and recognition are key you cant treat it unless you know what it is satis epilepticus is a seizure that lasts greater than five minutes some of you in this room might be old enough to remember that we used to say 30 minutes since then us neurologists have kind of come to our senses and realize yeah we probably shouldnt be waiting that long so its greater than five minutes or multiple seizures without return to baseline in between it further breaks down into convulsive and non convulsive convulsive is the generalized tonic-clonic that everybody is used to thinking about and non convulsive basically looks like a coma it often gets confused with brain death there are a lot of numbers here but all I want you to take away from this is that early recognition and adequate treatment significantly affects your mortality so knowing that when should you suspect seizures in the ICU there are really three circumstances right your patients way sleepier than you expect them to be the patients doing something weird and you really dont know why or the patients actually awake enough to report to you an experience that you

cant otherwise explain so next week youre going to be in your ICU and youre going to be looking at one of your patients youre gonna think oh my gosh I think this patient is having a seizure so just like any other medical emergency I want to refer you to my favorite quote from the house of God which is at a cardiac arrest the first procedure is to take your own pulse theres an algorithm and its really really easy so first you give it benzodiazepine then you give an antiepileptic right loading dose and maintenance dose and then you call neurology or neurocritical care were gonna help you figure out what you need to order and how to address why your patient is seizing the most common pitfalls people dont dose the drugs appropriately ativan should technically technically be given a point 1 milligrams per kilogram IV split up into 4 milligram doses every 5 to 10 minutes that means that a 75 kilogram adults is going to get 7 point 5 milligrams of ativan which I know sounds super scary but you got to get after it because intubating the patient is better than literally letting their brain fry from all of the seizures youre AEDs are your real workhorses these are the things that are actually going to make a big difference if youre confident enough to

phenytoin or valproate Im confident by Im confident that youre gonna give the correct dose keppra is where people run into a lot of issues and thats because the most recent data on Capra suggests that in order to treat status epilepticus you should be giving 60 milligrams per kilogram up to 4.25 grams that means that a 75 kilogram adult should get the max dose every single time so lets say youve done all that and it didnt work dont worry this is where you sedate the patient its most commonly done with propofol or versed but theres more recent evidence suggesting that ketamine might also be affected and you just titrate it to cessation of seizure or first impression and thats it so you take no messages are if it doesnt make sense think about seizures you should have a low threshold to call a neurology or at least order an EEG and if you have a high suspicion for seizure clinically or electro graphically treat it as soon as possible use your algorithm dont your benzos and 80s appropriately use sedation if you need to and call neurology to help you work out and figure out why your presentation is seizing in the first place for more information you can point your phone at this and it should download the neurocritical care society guidelines for you thank you you you

Critical, Care, Status Epilepticus, Seizure, ICU
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