Great episode as always but I am concerned about some of the doses that you mentioned in your summary. As you alluded to, seizures have a kindling effect: they longer they go on, the more difficulty it is to stop the seizures. Specifically
1) For adults, The initial dose of lorazepam should be 4mg not 2mg as mentioned in the summary or 10mg of midazolam. http://www.nejm.org/doi/full/10.1056/NEJMoa1107494#t=article
2) The correct dose of levetiracetam is not 1g but 60 mg/kg to maximum of 4500mg. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4749120/
3) The correct dosing of valproic acid in status epilepticus is 40mg/kg to maximum dose of 3000mg. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4749120/
There is a current multicenter trial examening the optimal 2nd line agent: Levetiracetam v. valproate v. fosphenytoin for status epilepticus
https://clinicaltrials.gov/ct2/show/NCT01960075
Would be happy to talk to you more about this subject as this is one of my interests.
Other important questions for the new onset seizure in 21 year old female: is she less than 6 weeks post partum? new meds - tramadol? Wellbutrin? Etc..
I would reconsider not using succinylcholine to intubate status epilepticus patients. I appreciate the risk of hyperkalemia but if you don't readily have access to continuous EEG monitoring (not sure about US, but very common in Canada) any other paralytic will result in you losing your ability to monitor seizure activity.
Ryan A. - August 4, 2017 1:33 AM
Will a Zip file be made available for download?
Tracy G. - August 7, 2017 2:41 PM
Ryan: You will find the zip file download at the very bottom of the "Downloads" pull-down menu.
Derek I., M.D. - August 9, 2017 3:18 PM
Great episode as always but I am concerned about some of the doses that you mentioned in your summary. As you alluded to, seizures have a kindling effect: they longer they go on, the more difficulty it is to stop the seizures. Specifically
1) For adults, The initial dose of lorazepam should be 4mg not 2mg as mentioned in the summary or 10mg of midazolam.
http://www.nejm.org/doi/full/10.1056/NEJMoa1107494#t=article
2) The correct dose of levetiracetam is not 1g but 60 mg/kg to maximum of 4500mg.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4749120/
3) The correct dosing of valproic acid in status epilepticus is 40mg/kg to maximum dose of 3000mg.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4749120/
There is a current multicenter trial examening the optimal 2nd line agent: Levetiracetam v. valproate v. fosphenytoin for status epilepticus
https://clinicaltrials.gov/ct2/show/NCT01960075
Would be happy to talk to you more about this subject as this is one of my interests.
Derek Isenberg, MD, FAAEM
Temple University
Cody B. - August 9, 2017 9:57 PM
Other important questions for the new onset seizure in 21 year old female: is she less than 6 weeks post partum? new meds - tramadol? Wellbutrin? Etc..
Tim V. - August 15, 2017 9:16 AM
I would reconsider not using succinylcholine to intubate status epilepticus patients. I appreciate the risk of hyperkalemia but if you don't readily have access to continuous EEG monitoring (not sure about US, but very common in Canada) any other paralytic will result in you losing your ability to monitor seizure activity.
Daniel L. - October 3, 2017 9:41 AM
FYI this episode does not appear in the iPhone EMRAP app
Tracy G. - October 6, 2017 12:43 PM
Daniel L. Please refresh your iPhone app again, and this C3 episode should now be available.