New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM. Digital resources and #FOAMed are curated and packaged by topic, following Brown EM's curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM community at large. Check out the theme song, the 'extras', and the discussion questions, and other modules -- and leave us your thoughts in the comments section. Follow us on Twitter at @AsynchronyEM.
Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.
This week in Asynchrony we're still in the Neuro/HEENT/Psych block (and will be until June!) Today we've got some must-know core content on seizures in the ED. Adults, kids, pregnant people -- we're covering lots of bases!
But no week in Asynchrony is complete without a theme song. This week: Shake It Off! (I'm just gonna shake shake shake shake shake shake...)
Haters gonna hate hate hate...learners gonna learn learn learn. Let's go!
1) From Core EM: ED Management of Seizures. Maybe not every first time seizure needs a head CT...more in our discussion section. Also, the jump to propofol for refractory SE is not a universal choice, although it is becoming more widely accepted (see EM Lyceum below --a couple of years old, and nary a mention of propofol. But it's definitely a thing now.)
2) ACEP Clinical Policy on Adult Seizures (2014). Four questions:
- In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the emergency department to prevent additional seizures?
- In patients with a first unprovoked seizure who have returned to their baseline clinical status in the emergency department, should the patient be admitted to the hospital to prevent adverse events?
- In patients with a known seizure disorder in which resuming their antiepileptic medication in the emergency department is deemed appropriate, does the route of administration impact recurrence of seizures?
- In emergency department patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures?
3) Four more questions from EM Lyceum . Click on the small link in the upper right to go from 'questions' to 'answers.'
- Which benzodiazepine do you prefer for the treatment of status epilepticus (SE)? Which do you prefer for pediatric patients?
- Which second-line agents do you use for treatment of SE?
- In which adult patients with first-time seizure do you obtain emergent imaging?
- How do you diagnose pseudoseizure (PNES)?
4) Don't forget to factor in medications/drugs that can contribute to or outright cause seizures, either in therapeutic use (by lowering the seizure threshold), in overdose (such as TCA's) or with elevated levels caused by drug interactions, or by withdrawal(benzos, alcohol). Or by any combination of the above.
Drug-induced Seizures: from MedScape/USPharmacist 2014. Just read page 6 (the linked page) and click through to table 3 at the end of the article for a list of commonly implicated drugs.
Note that missing from the Medscape table are the QUINOLONE antibiotics which also can also lower the seizure threshold (browse this EP Monthly article and specifically read the section on neurologic complications of therapy.)
Aside: Don't forget to ask family or rescue or whoever can help you to double check the house for meds/drugs when things just don't add up. I learned that for the oral boards, but it's saved the day a couple of times for me in practice.
5) When the patient doesn't come back to their right mind, keep this in yours: Non-convulsive Status Epilepticus . What could you be missing? From EM Docs.
Now on to the kiddos!
6a) An AliEM post from 2013: "Pediatric febrile seizures: when do I need to do an LP?"
OPTIONAL: A good, solid, Steve Carrol EM Basic Review on Febrile Seizures. 30 minute podcast with show notes available for download.
b) Neonatal Seizures , from PEM Morsels
7) Segue from peds to OB: Eclampsia - a quick bullet point review from LITFL that hits all the main points to remember. (Except, somebody help me: what are GTN and SNP? I'm drawing a blank. At least they're very far down the list...) TWO KEY WORDS TO ASSOCIATE: peripartum, and magnesium. (You won't forget the mag, but don't forget that it can happen postpartum! One-third!)
8) Just to squeeze it in, because the boards love it: isoniazid induced seizures, a quick case report review blurb from The Poison Review. Bottom line: I say isoniazid, you say what? ("Pyridoxine!" Yes! Good job.)
THE OPTIONAL EXTRAS:
1) Mallory's Hope: a different kind of EM:RAP podcast (November 2014)--the story of a girl with intractable epilepsy, and the lengths her emergency physician father goes to to find a treatment that might help her.
2) Seizure alert dogs fascinate me. (How do they do it?! And how do the trainers do it? My dog is not this smart. Or maybe it's his trainer's fault--that would be me...) A brief NYT article on the subject.
3) Ten facts about neurocysticercosis, from the World Health Organization. A common cause of seizures worldwide.
That's it! Brown residents, remember you have to finish the module in Canvas to receive asynchronous credit.