How do you manage patients who present in status epilepticus, knowing that "time is CNS function"? The longer patients remain seizing, the greater their morbidity and mortality.
Did you know that one study showed that 48% of their patients who presented in generalized convulsive status epilepticus (GCSE) had subtle persistent GCSE on EEG, despite no clinical evidence of overt seizure activity? That's scary.
Do you send off a serum tricyclic toxicology screen for all your patients with GCSE? Because of the prevalence of TCA overdoses locally, our Neurology consultants definitely order it. We are picking up a surprising number of positive tricyclic tox screens.
Summary of medications used to manage GCSE:
(from figure 1 of article)
Feel free to download this card and print on a 4'' x 6'' index card.
Shearer P, Riviello J. Generalized convulsive status epilepticus in adults and children: treatment guidelines and protocols. Emerg Med Clin N Amer. 2011, 29(1), 51-64. PMID: 21109102
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Lots of false positives and false negatives with TCA testing... not a test to "hang your hat on".
ReplyDeleteCory, I didn't know that! Urine TCA testing is really horrible. Serum testing is better but has false +/-s as you say. For instance, benadryl and flexeril cause false positives! And TCA levels do not actually correlate with clinical toxicity.
ReplyDeleteThanks for letting me know.
Firstly - I'm a big fan of your site!
ReplyDeleteI would like to see something added to this card, however. In patients with refractory seizures INH toxicity should be considered. I wouldn't go so far as to say that emperic pyridoxine should be started, but it should at least be considered.
Also, I commend you for pointing out that the benefit of faster infusion of fosphenytoin is mostly cancelled out by the time it takes to convert to active drug.
@Metaphysician: Thanks for the comment. INH toxicity indeed should be considered. It's always one of those pesky EM Board questions that they have.
ReplyDeleteAlso, I find that fosphenytoin is primarily preferred for status epilepticus from a nursing standpoint. So much easier to bolus slowly than hang a calculated drip, since they have a bunch of other things going on in the resuscitation.
@Metaphysician: Oh, and I changed the PV card to reflect the B6/INH toxicity point. They didn't mention in the article but worth adding. Thanks!!
ReplyDelete