Abstracts

CSE is a medical emergency with significant risk of mortality and neurologic sequellae. Prompt treatment may reduce this risk., We designed a protocol for the treatment of CSE according to the recommendations found in the literature and the pharmacological agents that are locally available. CSE was defined as generalized tonic-clonic (or tonic in children) seizure activity beyond 5 minutes or repeated seizures without return of normal level of consciousness.
The protocol was presented to the emergency, neurology and pediatrics departments with the goal of optimizing treatment of CSE at the Sherbrooke University Hospital. The major recommendations include optimal support therapy at onset, lorazepam at minute 1, phenytoin at minute 5 and a choice of propofol, phenobarbital or midazolam for refractory seizures.
A retrospective review of 19 episodes of CSE from January 2005 to May 2006 was then performed. The initial management, investigation and use of antiepileptic agents were evaluated. Where possible the doses and the timing of administration were also evaluated and compared to the recommendations proposed in the protocol., 13 cases of CSE were identified in adults (12 patients) and 6 in children (4 patients). A clear etiology was found in 18 cases.
Supportive treatment and initial investigations were generally appropriate. In all cases, patients received lorazepam. 9 received less than 50% of the recommended dose and significant delays ([gt]5 min since management began) occurred in 4 cases. In 11 cases, lorazepam was administered in a stepwise, incremental manner.
Phenytoin was indicated in all 19 episodes and administered in 15. Five adult patients received 1 gram IV without titration to weight, contributing to a low dose. It was administered at a rate [lt] 30 mg/min in 4 adult cases. Perfusion was initiated only after significant delay ([gt]15 min since management began) in 8 cases.
Patients were intubated in 10 cases. Two patients who were intubated had received sub-optimal initial treatment. In both, seizure activity stopped when provided intubation induction agents.
CSE persisted from [lt] 10 minutes to 45 minutes from onset of management.
EEG monitoring was performed in 7 patients, none had residual seizure activity. One patient had continued seizure activity subsequent to administration of initial agents; it was controlled with intubation induction agents., We found a tendency to administer medications below the recommended doses. In some, significant delays occurred prior to treatment. A tendency to administer lorazepam in an incremental manner contributed to delays in optimal treatment in some cases. Closer adherence to recommendations is suggested to minimize duration of seizure activity.,