Status Epilepticus

Status Epilepticus

Background

• Definition

  • >5 min of seizure activity without response to treatment // recurrent seizure without return to baseline mental status

• mortality is 22%

• can be convulsive or non-convulsive (tricky)

  • non-convulsive can be change in behavior/complete loss of consciousness with signs such as twitching/blinking/eye deviation

  • eeg shows continuous epileptiform discharges

• get a fingerstick/BGM

• ABCs

  • try to place in left lateral decubitus position (can aspirate)

  • place a NC/NRB/LMA early

    1. intubate if benzos are not breaking the seizure

       • this is obviously at the discretion of the team, best to consider all circumstances…intubate if you need to

       • standard RSI is fine but if at all possible, then try to use induction agent only

         • paralytic can mask seizures and put them in non-convulsive state

           • if must use, then succ is quicker on/off

  • IV line for meds (IO/IM/IN if desperate)

Treatment

• First line: Benzos

  • Not controversial, should be first line

  • Versed

    1. If no IV, then give versed IM or IN

  • Ativan

  • Valium

  • Try to use weight based dosing the way we do in peds

  • *if no response after 4 min, give another dose

• Second line: depends

  • Traditionally:

    • Phenytoin 20 mg/kg IV

    • Fosphenytoin 20-30 mg/kg IV (/IM)

    • Keppra 40 mg/kg IV (max 4.5g)

  • BUT, consider anesthetic instead

    • Propofol 1.5-2mg/kg IV

      • followed by 20-200mcg/kg/min drip

      • can add Ketamine 1mg/kg IV to propofol

    • Phenobarb 15-20 mg/kg over 10 min

      • followed by 5-10mg/kg after 10 min

      • followed by .5-4mg/kg/hr drip

      • May not be as readily available as propofol/ketamine is in your ED

    • **still hang the phenytoin/keppra even though you’re giving them an anesthetic, will need long term anticonvulsant on board anyway

• Eclampsia

  • give 4g magnesium IV

**management slightly different in peds 

Find the cause

• infectious

• eclampsia

• INH

  • Give pyridoxine (1g for every 1g of INH taken….or can just give the max of 5g empirically)

• Hyponatremia

  • 3% NaCl 2ml/kg q 10 min

    1. if in a pinch, then give amp of bicarb (consists of 6% NaCl) which will always be available somewhere in a code cart

• Alcohol withdrawal

  • High dose benzos, but also consider propofol/phenobarb if need to

• Drugs

• Metabolic

First10EM

wikiEM

Vaping/VAPI

Vaping and Vaping Associated Lung Injury (VAPI)

Background

• What is vaping?

  • The process of inhaling/exhaling aerosol (aka vapor) produced by an e-cigarette or other similar (handheld, and now commonly, portable) device.

  • These devices are thought to be “safe” by the general public because they do not produce tobacco smoke. Instead, they produce aerosolized vapor that contains harmful particles, which the public also mistakenly believes is just harmless water vapor (its not...).

• Around since 2007ish when the e-cig first came out.

  • Now, there are a ton of vaping pens/devices (juul, zip, mods, insert cool name here, etc.)

• Vape device consists of a mouthpiece, battery, pocket for e-liquid/juice, and a heating component

• E-liquid contains propylene glycol or vegetable glycerin liquid with nicotine and other chemicals/flavorings (yes, even crème brule...)

  • Again, not tobacco, but don’t be fooled…

    1. One juul pod/cartridge (~200 puffs) has the same amount of nicotine as 1 box of cigarettes.

  • Many people vape THC and synthetic drugs as well

• Has led to 500+ illnesses and 8 deaths across the US

  • Possibly linked to contaminated THC based vape cartridges

    1. Similar to other drugs, distributors (usually on the black market) are possibly cutting their product with other dangerous and cheaper substances

       1. Specifically, vitamin e acetate, an oil that could cause lung inflammation if not heated up properly during vaping

          • Most recent development linked to two brothers/illegal cannabis vaping ring in Wisconsin. Check it out here.

• If you have a suspected case, then please call the poison control center and/or call a tox consult depending on where you are working

  • per Dr. Harmouche, our awesome toxicologist (by the way, thanks for the useful info!), the poison control center can report to the DOH who can then decide to investigate/test samples.

    • the national toxicology registry is also collecting cases for research purposes.

• *if you have a patient (especially young one) who has worsening respiratory symptoms, please be diligent and ask about a vaping history in the last 90 days. They may have the below condition, which can cause them to deteriorate quickly if unnoticed and untreated.

VAPI

• Young patients (~20 YOs), but can affect any age group

• ~75% male

• ~80% of cases reported vaping with THC

• ~94% vaped within a week of symptom onset

• 100% have some sort of constitutional symptom

  • fever, chills, fatigue, weight loss

  • 29% of victims have presented febrile

• 98% have respiratory symptoms

  • SOB, cough, chest pain, hemoptysis

  • URI symptoms not common (rhinorrhea, sneezing, congestion)

• 81% have GI symptoms

  • n/v/d, abdominal pain

• CXR

  • Commonly shows BL infiltrates

  • Worsens quickly

• CT chest

  • Should be obtained in suspected cases

  • Will show BL groung glass opacities (see below, very impressive)

  • May also see pleural effusions, pneumomediastinum, and tree-in-bud opacities
    

• Labs

  • CBC may show leukocytosis

    1. May show eisopnipholia

  • ESR and CRP likely to be elevated

  • RSV, flu, HIV testing if indicated

  • Consider legionella testing

• Diagnosis of exclusion

  • And may not need a bronchoscopy if the rest of the work up (mainly infectious/malignancy) is negative, and other parts of history don’t provide more likely diagnosis/explanation for respiratory findings

• Treatment

  • Antibiotics until PNA excluded

  • Steroids (1mg/kg/day)

  • May need intubation (30% of cases already)

• Takes several days to recover

• The unknown

  • Pathophysiology of it all unclear

  • Possibly lipoid pneumonia from bad ccannabis oil/liquid being vaped

    1. Vitamin e, mentioned above, has been recently been used as aliquid carrier

       1. This is harmful

  • OR different cases may have different pathophysiological processes going on

    1. Again, unclear

emcrit

CDC

Second Victim Syndrome

Second Victim Syndrome (SVS)

Background

• Medical errors are the third leading cause of death in the US

• Poor outcomes can be due to a larger system failure or a human error

• Examples include incorrect medication dosages, improper management, harm during a procedure, missed diagnoses, etc.

• Second victim

• Defined in 2000 by Albert Wu

• In situations where medical errors are made or safety is compromised, the first victim is the patient and the second victim is the healthcare professional (EMT, nurse, physician) who can also be affected or traumatized by the event.

SVS

• Aforementioned events can have a lasting impression on a provider

• He/she tends to repeat the event over and over in his/her mind leading to emotional distress and scars

• Immediate symptoms

• Anxiety, guilt, shame, sadness, fear, anger

• Can have sympathomimetic manifestations—tachycardic, elevated BP, etc

• Later symptoms

• Depression, loss of confidence, loss of job satisfaction, hypervigilance, poor decision making

• Can develop PTSD like symptoms

• Insomnia, flashbacks, SI, isolation

Identifying Second Victims

• Symptoms and behavior can be similar to those who suffer from burn out

• Different stages of SVS (see below)

Management

• Support from colleagues is helpful

• Provides a sense of shared understanding

• M&Ms/patient safety conferences that are supportive instead of punitive

• Culture change

• Shift toward a “Just Culture”

1. Balancing accountability and support instead of perpetuating a blame/shame culture

• TRUST mnemonic

• Treatment that is Just

• Respect

• Understanding and compassion

• Supportive care

• Transparency and opportunity to contribute