Template for plan of management (Status Epilepticus) Plan:
Neurological:
– Neurological checks q1h
– Seizure, fall, aspiration precautions
– SBP goal 100-140
– CTH:
– Continous video EEG ordered
– Burst Suppression:
- Midazolam drip starting with 0.05mg/kg/h up to 2mg/kg/h till burst suppression is achieved
- Will continue burst suppression for at least 24h after last seizure (clinical or electrophysiological)
- Once burst suppression is completed, will taper down sedation over 24h.
– Meds:
- Midazolam drip (starting at 0.05 mg/kg/h, titrate up to 2 mg/kg/h)
- Fentanyl drip starting with 25mcg/h for analgesia while on mechanical ventilation.
- Continue on home AED medications (***)
- Propofol will be on board if further sedation is required for mechanical ventilation.
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Respiratory:
– Aspiration precautions, head of bed above 30 degrees
– Chest PT with vest q4hr
– Daily CXR while intubated
– Suctioning q1-2 hours
– Meds:
– Duonebs q4h
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Cardiology:
– Continuous cardiac telemetry
– SBP goal 100-140
– Meds:
-Labetalol 10mg IV q4h prn
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Renal:
– Renal function normal
– Monitor daily BMP, Mg, Phos
– Foley with temperature probe for strict I&O monitoring in critical care setting
– Avoid hypotonic fluids as this can worsen cerebral edema
– Meds:
– IVFs with NS at 75/h
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Gastrointestinal:
– NPO
– Place Dobhoff tube for medication/nutrition; Abdominal X-ray to confirm placement ordered
– Start tube feeding with Peptamen 1.5 @ 10cc/hr and titrate to goal 50cc/hr as tolerated
– Hold TF for residuals > 300
– Last BM: unknown
– Meds:
– Docusate 100 mg PO TID
– Famitidine 20mg tab bid
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Endocrinology:
– FSBS q6hr while NPO/TF
– Check HgbA1c, TSH
– Meds:
– Insulin SS
– Hypoglycemia protocol
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Hematology:
– Monitor CBC daily
– SCDs, enoxaparin 40mg daily for prophylaxis
– Meds:
– Enoxaparin 40mg q24h
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Infectious Disease:
– Current access: PIVs (placed)
– Keep normothermic, aggressive fever control as this worsens neurological outcomes
– Meds:
-APAP 500mg q6h prn fever > 38.3
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Prophylaxis:
DVT: SCDs, enoxaparin 40mg daily
GI: famotidine, docusate
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Consults:
Nutrition
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Discharge Planning:
Patient requires ICU level of care for monitoring while on mechanical ventilation.
Patient was discussed with the neurocritical care attending who agrees with current plan of management.
Important Links:
Status Epilepticus Protocol from MGH
Guidelines for Treatment of Status Epilepticus from Neurocritical care Society
Status Epilepticus Treatment in Infants and Children from BCMJ