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Paper Chase 1: ACEP on First Time Seizures

Sanjay Arora, MD and Mike Menchine, MD
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12:43
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Nurses Edition Commentary

Mel Herbert, MD MBBS FAAEM, Lisa Chavez, RN, and Kathy Garvin, RN
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00:39

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EM:RAP 2014 August - Summary 1 MB - PDF

More analysis of one of the most important critical care papers of 2014.

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jrlexjr -

When I came to an academic center from community practice, I found that everyone was giving a loading dose of phenytoin 1 gram. I have spent 11 years trying to teach residents that the loading dose of phenytoin is 15-20 mg / kg. Now you go tell everyone that the loading dose is 1 gram. The show notes say "There is no recommended strategy for loading orally." Look at the ACEP Clinical Policy again - Table 2 says "20 mg/kg divided in maximum doses of 400 mg every 2 h orally,or 18 mg/kg IV at maximum rate of 50 mg/min." Unless the patient weighs 50 kg, 1 gram is not the appropriate loading dose. I am VERY glad to see that you mentioned that we do NOT have to give a doze of benzo to "prevent the next seizure." This was disproven years ago, but is very difficult to get out of people's armamentarium.

Robert N. -

You mentioned that the patient needs to have a workup for provoked causes (i.e. blood work, head CT, etc). As I understand it, head CT for a first time seizure patient who is back to baseline and has a negative neurologic exam completed by yourself in the ED does not need a head CT. Correct?

Amelia Pond -

The majority of our faculty have been giving 1,000 mg of p.o. Dilantin with a large glass of water for years, for loading and discharge when they've seized, been off meds. I have never, and I mean, never, in the last ten years had a patient vomit that gram dose back up. They tolerate it just fine, they discharge to home when they're done, in my humble experience. There is, btw, literature to back this practice up, as per the show mentioned.

Kevin M., MD -

I was actually in the camp of not starting seizure medications on patients with first time uncomplicated seizures, but if the 6 week risk of a second seizure is 10%, I might have to change my stance. That's a huge risk for a potentially fatal event IMO.

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Episode 155 Full episode audio for MD edition 275:00 min - 131 MB - M4AEM:RAP 2014 août Résumé en Francais Français 65:33 min - 60 MB - MP3EM:RAP 2014 August Aussie Edition Australian 73:57 min - 102 MB - MP3EM:RAP 2014 August Canadian Edition Canadian 30:52 min - 43 MB - MP3EM:RAP 2014 Augusto Resumen Español Español 83:27 min - 77 MB - MP3EM:RAP 2014 August MP3 359 MB - ZIPEM:RAP 2014 August - Summary 1 MB - PDFEM:RAP 2014 August Board Review Questions 379 KB - PDFEM:RAP 2014 August Board Review Answers 421 KB - PDF

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