Seizures/Epilepsy

Treatment steps for status epilepticus

1. Stabilization phase

   • Fix any reversible causes of ongoing seizures

   • ECG, establish airway, breathing, circulation (ABC)

2. Initial treatment phase

   • Benzodiazepines (IV, nasal/rectal alternatively)

3. Second treatment phase

   • Non-benzo ASM (IV)

4. Third treatment phase (refractory)

   • Repeat second-line treatment or benzo, propofol

What class of analgesics are MOST like to cause seizures

Types of anti-infectives that can cause seizures

Psych meds that can cause seizures

Opioids (especially tramadol and meperidine)

Beta-lactams → PCN, carbapenems, cephalosporins
Quinolones
Mefloquine

Bupropion
Clozapine and other antipsychs
Lithium
TCAs

How to use Diastat AcuDIal? What drug is it?

Diazepam rectal gel

Dial to correct dose before dispensing
Lock the dose into syringe so that it says ‘READY’
Make sure to do it with BOTH syringes

Which ASMs increase the effect of GABA?

Benzos
Phenobarbital

What medication acts by both inhibiting Na channels and increasing GABA

Valproate

What ASM acts by binding SV2A proteins and inhibiting vesicle fusion?

Levetiracetam

What ASMs act by blocking Na channels?

Carbamazine/Oxcarbazepine
Phenytoin/Fosphenytoin
Topiramate

What ASM acts by both blocking Na channels and decreasing glutamate?

Lamotrigine

What ASM acts by blocking T-type Ca channels?

Ethosuximide

Generic: Lamotrigine


Dosing?

Brand: Lamictal


Loading dose + Maintenance

What is the lamotrigine BLUE kit?

What is the lamotrigine ORANGE kit?

What is the lamotrigine GREEN kit?

Blue = Lower starter dose → Use with enzyme inhibitors (valproate)

Orange = Standard starting dose

Green = Higher starting dose → Use with enzyme inducers (phenytoin, carbamazepine, phenobarbital)

Boxed Warnings of lamotrigine

Warnings

Side Effects

Skin reactions (SJS/TEN)

DRESS

Alopecia
Blurred vision/diplopia
Ataxia/tremor

Generic: Levetiracetam

Brand: Keppra

Levetiracetam warnings

Side effects

IV':PO ratio

MAJOR interactions?

Psych reachings (psychotic symptoms, fatigue, somnolence)

Somnolence, dizziness, weakness, asthenia


1:1

NONE!!!

Generic: Topiramate

Brand: Topamax

Topiramate warnings

Side effects

Monitoring

Metabolic acidosis, oligohidrosis/hyperthermia, nephrolithiasis, narrow glaucoma/vision changes, hyperammonemia, fetal harm

Somnolence, memory/concentration/attention disturbances, weight loss/anorexia

Bicarbonate, intraocular pressure

Generic: Divalproex

Brand: Depakote

Valproic Acid/Depakote
Boxed Warnings

Warnings

Side Effects

Major interactions

Hepatic failure
Fetal harm
Pancreatitis

Hyperammonemia
Thrombocytopenia

Alopecia
N/V
Weight gain/changes
Somnolence, tremor

Can increase lamotrigine and warfarin levels (increase INR)

Generic: Lacosamide

Brand: Vimpat (C-V)

Warnings of lacosamide

Side Effects

Increased risk of arrhythmia (prolonged PR)
DRESS

Euphoria, dizziness/headache, diplopia/blurred vision, ataxia

Generic: Carbamazepine

Brand: Tegretol

Boxed Warnings of carbamazepine

Warnings

Side Effects

Major interactions

Skin reactions (especially in HLA-B 1502 patients)
Aplastic anemia
Agranulocytosis

Myelosuppression

Dizziness, ataxia, pruritis, photosensitivity

CBC with differential, AUTOINDUCER

Generic: Oxcarbazepine

Brand: Trileptal, Oxtellar

Warnings of oxcarbazepine

Side Effects

Skin reactions (especially in HLA-B 1502 patients)
Hyponatremia

Somnolence, dizziness, N/V, visual disturbances, ataxia/tremor

Generic: Phenytoin

Brand: Dilantin

Generic: Fosphenytoin

Brand: Cerebyx

Phenytoin/Fosphenytoin
Boxed Warnings

Warnings

Side Effects

Dosing limits (IV)

• P = 50 PE/min

• F = 150 PE/min

Extravasation/purple glove syndrome
Skin reactions (especially in HLA-B 1502)
DRESS
Fetal harm

Acute → Nystagmus, ataxia, hepatotox
Chronic → Gingival hyperplasia, hepatotox

Phenobarbital
Contraindications

Warnings

Side effects

Severe hepatic impairment, dyspnea, previous addiction

Substance use disorder
Respiratory depression
Fetal harm

Physiological dependence
Tolerance
Residual sedation

Other ASMs
Cannabidiol → Brand

Ethosuximide → Indication, warnings

Felbamate → Boxed warnings

Gabapentin/Pregabalin → Brand names, main use

Zonisamide → Contraindication, side effects

Epidiolex

Used in absence seizures, can SJS/TEN, blood dyscrasias

Aplastic anemia, hepatic failure

Neurontin/Lyrica, mainly used for neuropathic pain

Use in sulfa allergy, oligohidrosis/nephrolithiasis