EM Quick Hits 7 Approach to Status Epilepticus, Codeine Interactions, Anticoagulation in Malignancy, Atrial Fibrillation Rate vs Rhythm Control, Peripheral Vasopressors, Motivational Interviewing

Topics in this EM Quick Hits podcast

Anand Swaminathan on a simple approach to status epilepticus  (0:31)

David Juurlink on codeine and tramadol interactions: nasty drugs with nastier drug interactions (8:37)

Brit Long on DOACS in patients with malignancy: which patient's with cancer can be safely prescribed DOACs? (13:05)

Ian Stiell on atrial fibrillation rate vs rhythm control controversy (20:55)

Justin Morgenstern on peripheral vasopressors: safe or unsafe? (26:39)

Michelle Klaiman on motivational interviewing that makes a difference to patient's lives (33:56)



Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Brit Long, Michelle Klaiman, Taryn Lloyd, Justin Morgenstern, and Sucheta Sinha, edited by Anton Helman

Cite this podcast as: Helman, A. Swaminathan, A. Juurlink, D. Long, B. Stiell, I. Morgenstern, J. Klaiman, M. Lloyd, T. EM Quick Hits 7 - Status Epilepticus, Codeine Interactions, Anticoagulants in Malignancy, Atrial Fibrillation rate vs rhythm control, Peripheral Vasopressors, Motivational Interviewing. Emergency Medicine Cases. August, 2019. https://emergencymedicinecases.com/em-quick-hits-august-2019/. Accessed [date].



Simplified approach to status epilepticus

Status Epilepticus: Any seizure lasting greater than five minutes including recurrent seizures that add up to five minutes without return to baseline consciousness.

Why it is bad? Prolonged seizure can lead to acidosis causing CV collapse and brain damage.

Step 1: Manage your ABC-DEFG - and Don’t Ever Forget the Glucose!



* Can consider giving glucose empirically vs a quick point of care check

* Get IV access with stat electrolytes on VBG to rule out hyponatremia

* Do a cursory history - think about the possibility of pre-eclampsia, which will require IV magnesium

* Get your airway equipment ready, though often do not need to rush to manage the airway



Step 2: Benzodiazepines are first line



Call for two doses of benzodiazepine so you have the second dose ready to go

* The most important determinant of stopping the seizure is time to first benzodiazepine dose - in a patient without IV access do not waste time. Give IM midazolam

Give ample doses: midazolam 0.15mg/kg IV or IM (about 10 mg) or lorazepam 0.1mg/kg (about 7mg)

If the seizure does not stop within a couple of minutes, give your second dose



Step 3: If benzos fail, propofol comes next



 RSI with propofol - can add ketamine and have norepinephrine on hand for potential hypotension



Step 4: Traditional anti-epileptic



Post intubation start your traditional antiepileptic; this can be fosphenytoin, phenytoin, or keppra.

Consider magnesium for pre-eclampsia, hypertonic saline for hyponatremia, and bicarbonate for TCA overdose.



Step 5: Get the patient to a place where an EEG can be placed to ensure there are no subclinical seizures

Expand to view reference list

Deep Dive: Episode 133 Emergency Management of Status Epilepticus



Tramadol and codeine drug interactions: Nasty drugs with nastier drug interactions