Benzodiazepenes
Josh is giving 0.1 mg/kg of Lorazepam (up to 8 mg)
Scott varies by scenario:
Seizing < 5 minutes
Nothing or 2 mg of lorazepam
Status Epilepticus (seizing >5 minutes, but <10 min)
If you have IV access:
Midazolam 5 mg IV
wait 2-3 minutes
Repeat Midazolam 5 mg IV
No IV:
RAMPART dose of 10 mg IM up front
Status Epilepticus (Seizing with EMS prior to arrival, >10 minutes seizing)
Midazolam 10 mg IV or IM (if patient did not get this dose in the field already)
Ketamine
Scott gives Ketamine 1mg/kg with his second dose of midazolam, or immediately following the first 10 mg dose in extended seizures
Ket-Mid Study
PMID [40186980]
Debate with First10EM on this Study
Scheppke Study
PMID: 39642307
F/u Retrospective Study with comparison group [DOI: 10.1016/j.annemergmed.2024.11.002]
Anti-Epileptics
We both start with Levetiracetam (Keppra) 60 mg/kg (max dose 4.5 g)
Give this whenever it is ready, but do not wait for it to work, if the patient is still seizing, move on to intubation and propofol
ESETT Trial looked at this dosing [10.1056/NEJMoa1905795]
2nd line anti-epileptic:
Lacosamide (Vimpat)
Major contraindications:
- Pre-existing heart block or conduction system disease.
- Underlying proarrhythmic conditions (ventricular tachycardia is reported in some cases).
- Severe hepatic dysfunction
Dose:
400 mg IV over 5 minutes (See IBCC for additional dosing info)
Meds for Intubation
Scott uses propofol and succinylcholine
Josh uses Ketofol and rocuronium (but lower dose, 0.5-0.6 mg/kg
have a low threshold to intubate these patients!!
General Anesthetic after Intubation
We both use propofol. Scott would consider switching to high dose midazolam drip after 48 hrs if the pt is still seizing.
You need higher doses of propofol to stop seizures, 80-100 mcg/kg/min
These pts will all need norepi, bring it to the bedside immediately after intubation
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
