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Toronto Notes 2019 Approach to Common ED Presentations
Investigations
• reserveimagingforsuspicionofemergencies,metastases,andpatientsathighriskoffracture,infection, cancer, or vascular causes
• WBC, ESR, CRP, U/A
Management
• treatunderlyingcause
• lumbosacralstrainanddischerniation:analgesiaandcontinuedailyactivitiesasmuchastolerated;
discuss red flags and organize follow-up
• spinal infection: early IV antibiotics and ID consultation
• caudaequina:dexamethasone,earlyneurosurgicalconsultation
Seizures
• seeNeurology,N18
Definition
• paroxysmalalterationofbehaviourand/orEEGchangesresultingfromabnormal,excessiveactivityof neurons
• statusepilepticus:continuousorintermittentseizureactivityforgreaterthan5minwithoutregaining consciousness (life threatening)
Categories
• generalizedseizure(consciousnessalwayslost):tonic/clonic,absence,myoclonic,atonic
• partialseizure(focal):simplepartial,complexpartial
• causes:primaryseizuredisorder,structural(trauma,intracranialhemorrhage,infection,increasedICP),
metabolic disturbance (hypo-/hyperglycemia, hypo-/hypernatremia, hypocalcemia, hypomagnesemia,
toxins/drugs)
• differentialdiagnosis:syncope,stroke/TIA,pseudoseizures,migraines,movementdisorders,
narcolepsy/cataplexy
History and Physical Exam
• history of seizures, identify potential precipitants (illness, alcohol use, sleep deprivation)
• precedingaura,rapidonset,briefduration,alterationsinconsciousness,tonic-clonicmovements,and
post-ictal symptoms would suggest a seizure
• commonsignsincludelossofbladder/bowelcontrol,tonguebiting,emesisandaspiration
• performvitals,completeneurologicexaminationandlookforinjuriestohead,spine,andshoulder
(dislocations)
Table 17. Concurrent Investigation and Management of Status Epilepticus
Emergency Medicine ER25
Timing Immediate
Urgent
Refractory
Investigate underlying cause: consider CT, LP, MRI, intracranial pressure monitoring Note: All interventions should be done as soon as possible
Adapted from Brophy et al. Guidelines for the Evaluation and Management of Status Epilepticus. Neurocrit Care 2012;17:3-23
Disposition
• decisiontoadmitordischargeshouldbebasedontheunderlyingdiseaseprocessidentified
■ if a patient has returned to baseline function and is neurologically intact, then consider discharge
with outpatient follow-up
• first-timeseizurepatientsbeingdischargedshouldbereferredtoaneurologistforfollow-up
Post-Seizure
Steps
Protect airway with positioning; intubate if airway compromised or elevated ICP Monitor: vital signs, ECG, oximetry; bedside blood glucose
Establish IV access
Benzodiazepine - IV lorazepam 2 mg at 2mg/min up to 10 mg or IM midazolam 5mg up to 10mg; repeat at 10 min if ineffective
Fluid resuscitation
IV dextrose if glucose <60 mg/dL
Give 50 mL 50% glucose (preceded by thiamine 100 mg IM in adults)
Obtain blood samples for glucose, CBC, electrolytes, Ca2+, Mg2+, toxins, and antiepileptic drug levels; consider prolactin, β-hCG
Vasopressor support if sBP <90 or MAP <70 mmHg
Establish second IV line, urinary catheter
If status persists, phenytoin 20 mg/kg IV at 25-50 mg/min in adults; may give additional 10 mg/kg IV 10 min after loading infusion
If seizure resolves, antiepileptic drug still required to prevent recurrence
EEG monitoring to evaluate for non-convulsive status epilepticus
If status persists after maximum doses above, consult ICU and start one or more of: Phenobarbital 20 mg/kg IV at 50 mg/min
Midazolam 0.2 mg/kg IV loading dose and 0.1-0.4 mg/kg/h
Propofol 2 mg/kg IV at 2-5 mg/kg/hr then loading dose then 2-10 mg/kg/h
Minimum Workup in an Adult with 1st Time Seizure
CBC and differential
Electrolytes including Ca2+, Mg2+, P043– Head CT
If administering phenytoin, patient must be on a cardiac monitor as dysrhythmias and/or hypotension may occur
If IV access is not feasible, midazolam 0.2 mg/kg IM up to 10 mg can be used for initial control of seizure in adults
Red Flags for Back Pain
Bowel or bladder dysfunction Anesthesia (saddle) Constitutional symptoms
K - Chronic disease, Constant pain Paresthesia
Age >50 and mild trauma
IV drug use/infection
Neuromotor deficits