Lorazepam 4mg repeat once in 5-10 minutes
2mg then give more. Start with 2
Midazolam no IV access 0.2mg/kg IV max 10mg, utilize IM if no IV access
Load
If past 5 minutes
Status load something
More popular medications
ESETT - established status epilepticus treatment trial
Valproate, keppra, phenytoin
Cardiac arrhythmias - fosphenytoin, phenytoind
Seizing 20-40 minutes
Intubating verside /
1500 IV
Make bag on the spot
ED 1500, then another 1500
versed
Adults 5-10
Inducers affect the doacs
Load give fosphenytoin
Maintenance to phentyoind
Max 1.5g
Maintenance 100mg IV TID
Osteoporosis, gingival hyperplasia, atrophy
depakote
Status load
40mg/kg max 3g, with meropenem vpa lowered in 1-2 days
May need meropenem
Increase lamotrigine levels need to decrease and monitor lamotrigine levels
Hard to tell if encephalopathic
½ is dialized need post HD dose
irritability
Newer cousin riveracetam more selective and less mood side effects
Status 300-400mg maybe 200 if 40kg. Avoid if 2nd / 3rd degree AV block
NES - nonepileptic seizures
pseudoseizures
10% of epilepsy patients
Co-morbid w/ epilepsy mood disorder
NES manifestations
Out of phase limb movement
Asynchronous jerk between L and R extremities
Tremors, threashing
Pelvic thrusting
Seen in epileptic seizures
Eye closure, forceful eye closure
80-90% of epileptic seizures eyes are open
\80-90% nonepileptic seizures eyes are closed
Variable <2mm open half the time for epileptic
Closed for nonepileptic
Tonic clonic
Tonic - stiff discharges slow down rhythmic twitching
Fast phase and slow relaxation phase
Nonepileptic seizures, side to side movement
Tonic clonic
Abdomen is tight.
Nonepileptic moaning groaning, hyperventilating flushed and pale.
Drowsy GTC, alertness convulsive PNES
Thermal burns
Post ictal
Gtc
Lacosamide (LCM) VIMPAT
Switch
Samuel Y Huang MD
PGY-2 Internal Medicine
Icahn School of Medicine
Mount Sinai South Nassau
One Healthy Way
Oceanside, NY 11572
(732) 289-8008
From: Huang, Samuel
Sent: Monday, February 10, 2025 1:42 PM
To: samuelyhuang2023@gmail.com <samuelyhuang2023@gmail.com>
Subject: Epilepsy monitoring Unit
Sent: Monday, February 10, 2025 1:42 PM
To: samuelyhuang2023@gmail.com <samuelyhuang2023@gmail.com>
Subject: Epilepsy monitoring Unit
Camera on ceiling to get bird's eye view see what the seizures look like, what they look like on video, gradually titrate off of medications.
MSW, MSH
Get episodes differentiate psychogenic non epileptic seizures
Establish when fall of rails
Presurgical work up if they are surgically resistant
Beta alpha theta delta
Occipital lobe, central lobes, mu rhythm goes away if you move
Beta rhythm faster awake at rem
If they get benzodiazepines or barbiturates
Mildly encephalopathic, slow, lethargic. Focal slowing
Focal dysfunction, post ictal structural lesion
Persistent, continuously low, structural lesion
Focal epileptiform
Epileptiform, hyper
Focal sharp waves
Interictal discharges - sharp waves seen in between the seizures
6 square centimeters
Measures currently extracellular outflow
Sharp and slow waves, child absence seizures.
EMG / muscle artifact bigger and more conlufence. Up straight up and down. Muscles faster than the nerves. Pulse artifact ballismic, if EEG on the temporal artery. Lines up with T.
Middle bigger wave, vertex wave - benign finding during stage 1 and 2 sleep.
Wider looking sharp looking spikes.
Eeg reports outside hard to trust other people's reads. Questionable seizure history, fainted.
capture.
Europe 50 hz
Wicket spikes - drowsiness and sleep
Rhythmic mid temporal benign discharges, spikey and sharp
Psychomotor variants
Until in psych patients
GRDA - generalized rhythmic delta activity - increased intracranial pressure, thalamic lesion. Not associated with increased risk of seizures.
Indicative of risk for seizures, rhythmically slow
Small piece of seizure. Similar to seizures in the past. Think about increasing medications.
IIC 1->2.5 hz of sharp waves over 10 seconds doesn't mean seizures but means close to a seizure and treated like seizures
Seizures increase risk of injury during seizures, aspiration, NYS law cannot drive for 1 year, NJ law 6 months but mandated reporting, quality of life, chronic memory
NJ 6 months but mandates reporting
State by state, ambiguous
Rare circumstances, chances of repeat seizure are low.
Over the years, many new medications
Keppra - third generation drug.
ASM - anti-seizure medications
ASMs - 66% 2/3 seizure meds
Resection 2/3-75%
Neocortical
Seizure freedom, if you can't resect, resect lateral connections
Prevent drop seizures
Three FDA approved devices.
Partial vs primary generalized
Comorbid conditions, drug interactions
Focal versus primary generalized
Epilepsy - spikes everywhere at once
Focal epilepsy from stroke / tumor
Medications for focal epilepsies that worsen others
IV versus PO version
Take into consideration elderly and pregnant
Broad spectrum - generally used - clobazem, lamotrigene, keppra, topiramate, valproate
Narrow spectrum
absence
Lacosamide
Ethosuximide absence seizures
Asm - antiseizure meds
Keppra SV2a vesicle receptor protein, help vesicles merge with protein into membranes.
Valproate sodium channel and gaba
Status epilepticus
Focal status epilepticus w/ impaired consciousness after 10 minutes
One arm is changing. Don't have to freak out until after 10 minutes
Stabilization phase
ABCs - airway,
Make sure patient is not hypoglycemic
IV thiamine before the dextrose.
Alcoholic, thiamine deficiency not a lot of sugar, get wernicke
Body is tonic / clonic
Initially phase 1mg/kg 4mg adults so heavy
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