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Adult Seizure and SE Adult Seizure and SE Patient ED Care:Patient ED Care:
CrossfireCrossfire
Edward P. Sloan, MD, MPH, FACEP1
Edward P. Sloan, MD, MPHEdward P. Sloan, MD, MPH
ProfessorProfessor
Dept of Emergency Medicine University Dept of Emergency Medicine University of Illinois College of Medicineof Illinois College of Medicine
Chicago, ILChicago, IL
Edward P. Sloan, MD, MPH, FACEP2
Attending Physician Attending Physician Emergency MedicineEmergency Medicine
University of Illinois Hospital
Our Lady of the Resurrection Hospital
Chicago, IL
Edward P. Sloan, MD, MPH, FACEP3
Edward P. Sloan, MD, MPH, FACEP4
Housekeeping IssuesHousekeeping Issues
• Disclosures by each speaker
• Meeting support from UCB Pharma–Thank you Dave Riccio
– IV levetiracetam, a second generation AED
–May soon be an IV parenteral option in the ED
• Please fill out a CME form with your email
• Please give feedback to improve our work
Edward P. Sloan, MD, MPH, FACEP5
Adult SeizuresAdult Seizures
• Common ED problem
• Seizures: 6% of EMS encounters
• Adult seizures: 1% of all ED visits
• 130 million ED visits
• 1.3 million seizure patient visits
Edward P. Sloan, MD, MPH, FACEP6
Management IssuesManagement Issues
• Address clinical concepts, dogmas
• Discuss clinical impact of the decisions that we make
• Explore how to improve adult ED seizure patient care
Edward P. Sloan, MD, MPH, FACEP7
Session FormatSession Format
• Clinical impression, belief
• Audience poll
• Input from our experts
• Review of the audience responses
• Discussion
• Any change in clinical perspective?
Edward P. Sloan, MD, MPH, FACEP8
Initial Benzodiazepine UseInitial Benzodiazepine Use
• It doesn’t matter which benzodiazepine is used to treat an actively seizing patient.
• In fact, diazepam is probably better, since it is equally efficacious and it lasts a shorter period of time, allowing for a return to a normal mental status sooner
Edward P. Sloan, MD, MPH, FACEP9
Initial Benzodiazepine UseInitial Benzodiazepine Use
Do you agree that it does not matter which benzodiazepine is used to treat a seizing ED patient?
A. Yes
B. No
Edward P. Sloan, MD, MPH, FACEP10
A Phenytoin Use (EtOH, Toxins)A Phenytoin Use (EtOH, Toxins)
• Even in settings where a phenytoin load is normally not clinically indicated (alcohol, toxin-related seizures), if a flurry of seizures or SE occurs, a phenytoin load should be provided
Edward P. Sloan, MD, MPH, FACEP11
A Phenytoin Use (EtOH, Toxins)A Phenytoin Use (EtOH, Toxins)
Do you agree that a phenytoin load should be given to alcohol or toxin-related seizure patients with a flurry of seizures or SE, even if a phenytoin is not normally used to treat this problem?
A. YesB. No
Edward P. Sloan, MD, MPH, FACEP12
Fosphenytoin Use in SEFosphenytoin Use in SE
• When a phenytoin load is to provided to a patient in SE, fosphenytoin should always be used because it can be infused more quickly and with fewer adverse effects.
• It is recognized that the time to achieving a therapeutic free phenytoin level is comparable with either fosphenytoin or phenytoin (tens of minutes).
Edward P. Sloan, MD, MPH, FACEP13
Fosphenytoin Use in SEFosphenytoin Use in SE
Do you agree that when a phenytoin load is to be given to a patient in SE, fosphenytoin should always be used?
A. Yes
B. No
Edward P. Sloan, MD, MPH, FACEP14
ED Fosphenytoin UseED Fosphenytoin Use
• There are many non-SE clinical settings in which the pharmacologic properties of fosphenytoin (water soluble, no toxic diluents, extravasations not complicated, IM use possible) justify its use in ED seizure patients despite the higher acquisition cost.
Edward P. Sloan, MD, MPH, FACEP15
ED Fosphenytoin UseED Fosphenytoin Use
Do you agree that there are many non-SE patients for whom ED fosphenytoin use is cost-effective because of its pharmacologic characteristics?
A. Yes
B. No
Edward P. Sloan, MD, MPH, FACEP16
ED IV Valproate UseED IV Valproate Use
• ED IV valproate is underutilized because of a lack of knowledge regarding its indications and clinical use, especially in patients who are taking PO valproate.–Broad indications
– Infusion at 300 mg/min, no infusion AEs
–Load 1 mg/kg, level increases 5 mcg/ml
–Therapeutic level can exceed 125 mcg/ml
Edward P. Sloan, MD, MPH, FACEP17
ED IV Valproate UseED IV Valproate Use
Do you agree that ED IV valproate is underutilized because of a lack of knowledge regarding its indications and clinical use, especially in patients who are taking PO valproate?
A. YesB. No
Edward P. Sloan, MD, MPH, FACEP18
ED 2nd Generation AED UseED 2nd Generation AED Use
• Emergency Department 2nd generation AED use is underutilized because of a lack of knowledge regarding their indications and clinical use, especially in patients who are taking oral 2nd generation AEDs as outpatients.–Clinical indications–Class clinical characteristics– Individual drug differences
Edward P. Sloan, MD, MPH, FACEP19
ED 2nd Generation AED UseED 2nd Generation AED Use
Do you agree that ED 2nd generation AED use is underutilized because of a lack of knowledge regarding their indications and clinical use, especially in patients who are taking 2nd generation AEDs?
A. YesB. No
Edward P. Sloan, MD, MPH, FACEP20
ED SE Patient RxED SE Patient Rx
• It doesn’t matter what drugs are used in what order in order to treat a seizing SE patients, as long as they are used quickly, in full mg/kg doses, and are ordered in parallel (the next drug is being ordered as one is being infused).
Edward P. Sloan, MD, MPH, FACEP21
ED SE Patient RxED SE Patient Rx
Do you agree that it doesn’t matter what drugs are used in what order in order to treat a seizing SE patients, as long as they are used quickly, in full mg/kg doses, and are ordered in parallel ?
A. YesB. No
Edward P. Sloan, MD, MPH, FACEP22
ED EEG UseED EEG Use
• I know when an EEG is indicated for ED patients that I treat for seizures and SE, and I can get one in those (rare) circumstances when it is indicated in order to rule out SE.
Edward P. Sloan, MD, MPH, FACEP23
ED EEG UseED EEG Use
Do you agree that you know when an EEG is indicated for ED patients that you treat for seizures and SE, and you can get one in those (rare) circumstances when it is indicated in order to rule out SE?
A. YesB. No
Edward P. Sloan, MD, MPH, FACEP24
Key Learning PointsKey Learning Points
• Many clinical dogmas
• Clinical priorities may alter practice
• Need to know priorities
• Therapies may be underutilized
• Clinical practice might be enhanced
• Need to know how to best treat ED seizure/SE patients with available Rx
Edward P. Sloan, MD, MPH, FACEP25
Management ImplicationsManagement Implications
• Know what therapies exist
• Make multiple drugs available
• Utilize them quickly, in parallel
• A protocol should exist
• Utilize EEG when necessary
• Improvements in patient care possible
Edward P. Sloan, MD, MPH, FACEP26
CME QuestionCME Question
Have you learned something new about treating adult seizure patients today such that you can change and improve your clinical practice?
A. YesB. No
Edward P. Sloan, MD, MPH, FACEP27
CME Follow-upCME Follow-up
CME providers require follow-up to assess if your learning has indeed improved your clinical practice. Can we ask you this question via email again in the future?
A. YesB. No
Questions??Questions??
ferne_aaem_france_2005_sloan_adultsz_fshow.ppt
9/2/2005 2:47 AM Edward P. Sloan, MD, MPH, FACEP
[email protected]@ferne.org
Edward P. Sloan, MD, MPH, FACEPEdward P. Sloan, MD, MPH, [email protected]
312-413-7490312-413-7490
