In this episode, I’ll discuss how a pharmacist can ensure the best possible outcomes for status epilepticus.
Whenever I encounter a hospital inpatient with an acute seizure, I make sure that I have IV lorazepam available. Most seizures stop after about 2 minutes. In reality, this means that by the time the lorazepam has been brought to the bedside, the seizure is usually over.
If the seizure lasts more than 5 minutes, the patient is now considered to be in status epilepticus.
Status epilepticus is a neurologic emergency and can result in respiratory failure, cardiovascular collapse, and neurologic damage if it is not terminated.
Some definitions set a seizure duration of 30 minutes for a patient to be considered in status epilepticus, however the 30 minute duration is actually how long it takes for an uncontrolled seizure to have the potential to produce permanent neuronal injury.
Rapid treatment is therefore essential for a good patient outcome.
The current guidelines for the treatment of status epilepticus are published by the American Epilepsy Society in 2016.
The guidelines broadly describe 3 phases of treatment for seizures that last more than 5 minutes:
First phase = Give a benzodiazepine which for most adult patients is IM midazolam 10 mg or IV lorazepam 4 mg or IV diazepam 10 mg.
Second phase = Give an anticonvulsant which for most adult patients is IV fosphenytoin 20 mg/kg (up to 1500 mg) or IV valproic acid 40 mg/kg (up to 3000 mg) or IV levetiracetam 60 mg/kg (up to 4500 mg).
If the seizure has not terminated after the second phase which generally is reached 20 to 40 minutes after the start of the seizure, proceed to the third phase = Give anesthetic doses of either thiopental, midazolam, pentobarbital or propofol.
So let’s say you’re a hospital pharmacist who has responded to a rapid response call for a patient with a seizure lasting more than 5 minutes – how can your actions best help that patient?
In my experience a pharmacist at the bedside can proactively ensure that the necessary medications are promptly available to support each treatment phase. That means engaging the physician and suggesting or identifying what the first phase benzo is going to be, and making sure it is immediately available at the bedside.
Whether or not the first phase benzo stops the seizure, the patient will be ordered an antiepileptic. So while the nurse is giving the first phase benzo, I engage the physician again to either suggest or identify what antiepileptic they desire so that can be immediately given.
By proactively focusing on the second phase antiepileptic choice, there is a much better chance that it will be available at the bedside to administer in a timely fashion than if the pharmacist passively waited for the physician’s order.
Once the antiepileptic is being administered, I will obtain propofol and other medications necessary to support intubation so that should the patient continue to seize and the physician desire to induce anesthesia, all of the medications necessary to do so are already at the bedside by the time that decision is reached.
Eliminating the lag time from obtaining medications for each of these phases should allow patients the best chance to have their seizure terminated before permanent neuronal damage occurs.
Beyond knowledge of medication dosing and administration for status epilepticus, pharmacists can help a rapid response team by searching for medication-related causes of the seizure and by requesting details to complete the search for the cause such as a fingerstick glucose value or a serum sodium value.
Members of my Hospital Pharmacy Academy have access to practical training from a pharmacist’s point of view on status epilepticus, airway pharmacology, code blue and rapid response participation, along with over 200 practical trainings and other resources to help in your practice. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Excellent
I’m finding that with the increased prevalence and utilization of the nasal rescue benzodiazepines, it’s more and more likely that a patient could arrive at the hospital with a full dose of diazepam or midazolam having been administered at home and then possibly a second benzo on board administered by EMS. This will become more and more common. Especially once the rescues are available as genetics. Not sure when that is.