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Seizure Management in the ICU
23 Plays2 years ago
In this episode, we discuss the management of seizures in the intensive care unit. Our guest is Dr. Brandon Foreman – an internist and neurologist with fellowship training in epilepsy and Neurocritical care. Dr. Foreman is an Associate Professor of Neurology at the University of Cincinnati Medical College. He is the Associate Director for Neurocritical Care Research. An excellent clinician, researcher, and educator focusing on Clinical Neurophysiology and Neurocritical care.
Additional Resources:
Seizure Management in the Intensive Care Unit. Boggs JG. Curr Treat Options Neurol 2021: https://pubmed.ncbi.nlm.nih.gov/34697528/
American Epilepsy Society – Website with multiple clinical Guideline: https://pubmed.ncbi.nlm.nih.gov/34697528/
Treating Rhythmic and Periodic EEG Patterns in Comatose Survivors of Cardiac Arrest. Ruijter BJ, et al. N Engl J Med 2022: https://pubmed.ncbi.nlm.nih.gov/35196426/
Books mentioned in this episode:
Siddhartha: A Novel. By Hermann Hesse: https://www.amazon.com/Siddhartha-Novel-Hermann-Hesse
Netflix- Reference Guide on Our Freedom and Responsibility Culture https://igormroz.com/documents/netflix_culture.pdf
Recommended
Transcript
Introduction and Overview
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
Seizure Management in the ICU
00:00:31
Speaker
In today's episode of the podcast, we will discuss the management of seizures in the intensive care unit.
00:00:36
Speaker
Our guest is Dr. Brandon Forman, an internist and neurologist with fellowship training in epilepsy and neurocritical care.
00:00:42
Speaker
Dr. Forman is an associate professor of neurology at the University of Cincinnati Medical College.
00:00:47
Speaker
He's the associate director for neurocritical care research.
00:00:50
Speaker
He's an excellent clinician, researcher, and educator who focuses on clinical neurophysiology and neurocritical care.
00:00:56
Speaker
Brandon, welcome to Critical Matters.
00:00:59
Speaker
Thank you so much, Sergio.
00:00:59
Speaker
I appreciate you having me on.
Prevalence and Risks of Seizures in ICU
00:01:01
Speaker
So I would like to start with a general question of why you think that clinicians working in maybe non-neurocritical care ICUs should care about this topic of managing seizures.
00:01:14
Speaker
That's a great question.
00:01:15
Speaker
I think it falls off the radar sometimes because we deal with so many other things and so many other problems.
00:01:22
Speaker
But I think two things come to play.
00:01:24
Speaker
One is this is actually something, and we'll talk about this, that's extraordinarily common.
00:01:29
Speaker
And I think we miss it if we don't think about it.
00:01:32
Speaker
And the second reason is that this kind of thing is something that often is a black box for us.
00:01:37
Speaker
It's something that we might be uncomfortable with, unfamiliar with, trying to work with our neurology partners on this and feel like, I'm not sure what you're doing, why you're doing this and what this means.
00:01:49
Speaker
And so I think kind of uncovering that open the black box a little bit actually helps us to feel more comfortable with that initial management and trying to get things under control when we start seeing seizures in those patients.
00:02:01
Speaker
Perfect.
00:02:02
Speaker
And you mentioned that it's more common than some people might think it is.
00:02:06
Speaker
Could you give us an overview of the epidemiology of seizures in the ICU?
00:02:12
Speaker
There's been a whole bunch of studies at this point that really point out or highlight the fact that this is something more common than we think of.
00:02:20
Speaker
And part of the reason for that is
00:02:22
Speaker
Somewhere in the order of 80 to 90% of the seizures that we end up dealing with in the ICU are non-convulsive, meaning you don't really see anything clinically.
00:02:32
Speaker
It may be a patient who's got waxing and waning confusion,
00:02:35
Speaker
or some periods of time where they don't seem to be responsive as they usually are.
00:02:40
Speaker
And that's all we got.
00:02:41
Speaker
And we have to kind of think about non-convulsive seizures to diagnose them.
00:02:45
Speaker
But in those studies where, you know, conducted in centers where there's a lot of continuous EG and a lot of people who are quick to apply that, the number of people with seizures with neurological illness is somewhere in the order of about 20%.
00:03:01
Speaker
But more importantly, in the studies from mixed ICUs, medical ICUs, surgical ICUs, the number of people who are having seizures with altered mental status that's otherwise unexplained is remarkably similar or consistent.
Identifying ICU Seizures
00:03:16
Speaker
It's about one in 10 of your patients who are comatose or encephalopathic without another explanation.
00:03:22
Speaker
And I think that another important aspect of why this should be of great interest to a lot of our listeners who may not be in a neuro ICU or neurocritical care practice is that as we have a growth and specialization of these units, some of these commonly seen neurological issues and non-neural pathology as a primary cause of admission might be overlooked and might be mismanaged.
00:03:54
Speaker
Right.
00:03:54
Speaker
Yeah, I think we often get in a situation where if we overlook this, these seizures can continue.
00:04:01
Speaker
They can go on.
00:04:02
Speaker
They can develop into something that's refractory, refractory status epilepticus, which we'll talk about a little bit later.
00:04:10
Speaker
And ultimately, the longer seizures go on, the more they end up impacting the brain, causing secondary brain injuries.
00:04:17
Speaker
And those have a lot of impact on patients' long-term recovery.
00:04:19
Speaker
Perfect.
00:04:20
Speaker
In general terms, how would you think of the main causes or categories of seizures in ICU patients?
00:04:27
Speaker
As opposed to what we know about seizures and status as they present in the ED, where more than half of those patients have a pre-existing diagnosis of epilepsy and maybe forgot a medication, maybe have a urinary tract infection, when it comes to the same disease process, seizures and status epilepticus in our ICU patients,
00:04:45
Speaker
The causes tend to be acute and symptomatic.
00:04:49
Speaker
So meaning they're stemming from something that's happening there and then, whether it's systemic inflammation in sepsis patients, for instance, who have an incidence of seizures about one in 10 patients.
Role of EEG in Seizure Diagnosis
00:05:01
Speaker
or it's a harbinger or a canary in the coal mine for something that's developing in the brain.
00:05:07
Speaker
Things like press, for instance, that might develop in your post-transplant patients, right?
00:05:11
Speaker
These are warning signs that something is happening to the brain.
00:05:14
Speaker
And so usually these causes are telling us something has changed, something's going on, and there's something we need to figure out and hopefully mitigate or treat.
00:05:23
Speaker
Perfect.
00:05:24
Speaker
Let's talk about diagnosis, Brandon.
00:05:27
Speaker
I feel that a lot of times in the ICU, especially outside of the confines of a neuro ICU, when somebody has what's thought to be a seizure or convulsions, people become very reactive and people kind of jump to do something.
00:05:43
Speaker
And I think often we overlook understanding what is happening first.
00:05:47
Speaker
So could you tell us a little bit about the value of history and observation and how you as a neurologist and neurointensivist would focus if somebody called you to the bedside for possible seizures?
00:06:00
Speaker
Yeah, this is, you know, this is a difficult thing because the manifestations of seizures are often really protean.
00:06:05
Speaker
So it becomes sort of a pretest probability game.
00:06:09
Speaker
I think knowing what the patient is there for, their history, but more importantly, how their exam or how their mental status has sort of been and progressed during their hospital stays is incredibly important.
00:06:23
Speaker
someone who comes in who's comatose from something that hasn't fully been reversed and remains comatose, there's a reason for that and your pretest probability may be lower.
00:06:33
Speaker
Whereas in someone who maybe had a reasonable mental status and that has declined in the absence of something else going on, say your CAT scan's normal and there's no other metabolic derangements, that kind of patient is somebody who you might have a much higher clinical suspicion
00:06:52
Speaker
And there's a lot of things that are associated with the development of seizures, too, that might raise suspicion.
00:06:57
Speaker
So those patients who their mental status isn't quite right, you're concerned something has changed and they're, say, on cefepime, or their sodium has fallen to 125, or, you know, they've got underlying other organ dysfunction, like renal dysfunction, liver dysfunction.
00:07:12
Speaker
These are all patients at high risk.
00:07:14
Speaker
So a lot of it boils down to are things happening that might be associated with that lower cefepime.
00:07:19
Speaker
seizure threshold or things developing that I'm not quite sure why in terms of that patient's neurological status, their mental status.
00:07:27
Speaker
And what I mean when I say that is their level of arousal and their ability to pay attention to you during an exam.
00:07:33
Speaker
And I think those two things end up being really critically important when you're observing the patient.
00:07:37
Speaker
So, you know, walking into a room and the patient is comatose, if that's new or that hasn't improved the way you would expect it to, those are people with a potentially high pretest probability.
00:07:48
Speaker
Those are the ones in the observational studies that have that high incidence of seizures.
00:07:54
Speaker
But when you sit and observe someone you're talking with, you're examining them, and your responses from that patient or your interaction with that patient change during the course of that exam, where they're not responding as well to you, and then suddenly they're able to again, or you get the history from your bedside nurse, your staff, those again are patients who you have to have a sort of lower threshold to do a diagnostic test and just see, is there something there that we can treat?
Treatment Approaches for Seizures
00:08:22
Speaker
because seizures are imminently treatable and as a treatable cause for encephalopathy, as a treatable cause for coma potentially, that's a really powerful thing that gives us the ability to make an intervention and a difference in that patient.
00:08:38
Speaker
Excellent.
00:08:39
Speaker
And you did mention some diagnostic testing.
00:08:41
Speaker
Could you just give us a little bit of an overview of how you would approach a patient who has new onset seizures in terms of laboratory and imaging, and then we can maybe dive a little bit deeper into the EEG and its role in the ICU?
00:08:55
Speaker
The first thing to, I think, think about when you've got someone who potentially is having seizures, or if they're clinically having a seizure in front of you, certainly, is
00:09:03
Speaker
is why there's always you know again most seizures in the icu are going to be acute provoked or symptomatic seizures so the question becomes okay why is this patient seizing in front of me oftentimes it's important to get laboratory studies and first and foremost get that finger stick blood glucose that's a common abnormality in a lot of our patients
00:09:23
Speaker
especially those on insulin.
00:09:25
Speaker
Maybe they've got an AKI and now they're just not processing their insulin as well, such that they now have hypoglycemia, right?
00:09:32
Speaker
So get the finger stick blood glucose very quickly and then move on to getting your routine labs.
00:09:38
Speaker
And by that, I mean things like your metabolic panel, right?
00:09:41
Speaker
Sodium is a common cause of lowered seizure threshold when it's super low.
00:09:46
Speaker
uh they may have other abnormalities calcium for instance as an abnormality or they've got new onset organ failure so look for those changes in in things that might lower your seizure threshold i tend to try to look for other causes that might be uh impacting that patient's body as well so things like infection inflammation so easy stuff to do is
00:10:09
Speaker
in a UA, right?
Managing Status Epilepticus
00:10:11
Speaker
And then you have to think about the brain.
00:10:14
Speaker
So is there something new that has happened in that person's brain that maybe we didn't expect?
00:10:19
Speaker
You know, a lot of our patients are on anticoagulation.
00:10:22
Speaker
A lot of our patients have histories of stroke or other neurological disorders.
00:10:27
Speaker
So there's a lot of risk there for many of these patients.
00:10:29
Speaker
In other words, so oftentimes, you know, we'll send labs, of course, up front, and then we'll
00:10:35
Speaker
often send them down for a diagnostic image and a CT of the brain will tell you a lot and give you some reassurance that there's not, you know, an acute hemorrhage or something, but gives you that starting block to say, okay, if I don't see anything, we definitely need to move on to an electrophysiologic test looking for those seizures in particular.
00:10:53
Speaker
What about the role of EEG and the initial diagnosis?
00:10:56
Speaker
I think we'll dive into continuous EEG later in our discussion, but just in terms of initial workup and how would you frame that within the context of an ICU?
00:11:09
Speaker
This has been sort of an evolving thing.
00:11:13
Speaker
The gold standard for the diagnosis of seizures in the ICU is continuous EEG, and part of that comes from the observational literature that suggests that a lot of the seizures that we might consider will hook someone up to EEG, and it takes a while for that patient to show you that they're having seizures.
00:11:30
Speaker
They may be sporadic, they may be episodic, and they may not happen for 18 hours.
00:11:35
Speaker
But the background that we'll talk about a little bit later, but the background does give you a hint that, wow, this brain is very irritable, very prone to seizing.
00:11:42
Speaker
So, you know, what was observed, I think, from the beginning of all of this is the continuous EG literature came out is that you really need a certain amount of time of recording those brainwaves to really pick up on, yeah, this patient is having seizures.
00:11:56
Speaker
In that timeframe tended to be recommended to be 24 hours of continuous EG for a patient who's got an exam.
00:12:02
Speaker
It's just maybe abnormal in terms of their mental status or arousal and attention.
00:12:07
Speaker
But in patients who are comatose, those seizures can be very sporadic, and most people will recommend 48 to 72 hours just to obtain that sensitivity to say, yes, this patient is not having seizures with 88 to 90% sensitivity.
00:12:22
Speaker
Now, that's begun to shift a little bit, and there's been some good literature that suggests that if you have a slow, but generally slow,
00:12:31
Speaker
normal or non-concerting EG in terms of epileptiform discharges and some of the other patterns we talk about, you may not need EG that long.
00:12:39
Speaker
It may be just several hours to feel comfortable that your probability of going on to develop seizures is low enough that they probably are not.
00:12:49
Speaker
And then more recently, there's been, I think, a shift even further to say, well, it may be enough to do point of care EEG, or even in some situations, particularly when we're resource limited, that routine EEG, when done perhaps several times, but certainly done as a way to detect non-convulsive seizures.
00:13:08
Speaker
may actually
Understanding EEG Patterns
00:13:09
Speaker
be enough as well.
00:13:10
Speaker
And there was a randomized control trial that was done actually comparing continuous EG to routine EG, suggesting they may actually have a reasonable sensitivity when you do a routine EG, as long as you're doing it on the right patient at the right time and following that up with a repeated study if you need to.
00:13:27
Speaker
um the bedside point of care eeg has been a really nice novel technology that we've started using and really what that boils down to is when you see a patient you have a concern you can put this device on and there's several companies that make them you can put a device on yourself it's very easy to do and it records within five or ten minutes and gives you an an output that suggests whether seizures are occurring or not and sometimes that's nice because you're seeing the symptoms and if you can capture that eeg right away while you're in there examining the patient
00:13:58
Speaker
again, you have a much better idea that, okay, what I'm seeing in front of me is seizure or not, as opposed to waiting for a full head montage and a read from your neurologist.
00:14:08
Speaker
So the diagnostics have really shifted.
00:14:10
Speaker
I think they've democratized to a point where anybody in any ICU can really diagnose these fairly quickly and fairly sensitively, depending on the resources you have available.
00:14:22
Speaker
And it also seems that what has moved in a different direction, as we understand more about this icto-interictal continuum and non-convulsive status we'll talk about, is that historically people think of seizures as convulsions, very dramatic convulsions.
00:14:42
Speaker
And in the ICU, for many, many reasons, there is an important number of patients who might not present like that in understanding
00:14:48
Speaker
when to do the testing and when to think about them, like you mentioned, when people are comatose and not responding in a way that we anticipated.
00:14:56
Speaker
These might be some of the hints that also lead us in that direction in the ICU.
00:15:02
Speaker
right i think having that that you know i think having that lower threshold to say maybe these are seizures just that maybe just that thought of these could be i think that being in your mind is a really important step to being able to diagnose these you have to think about them if you want to diagnose them and so it's important to to keep that in your mind especially in those patients who
00:15:26
Speaker
they're just not acting the way you want them to act.
00:15:29
Speaker
They're not waking up when you want them to wake up or as you expect them to wake up, or they're way deeper than you expect them to be based on what you know about that disease process or other patients that you've taken care of.
00:15:40
Speaker
So keeping it in mind, the front of your mind, I think is a really important step to diagnosing these seizures.
00:15:46
Speaker
And in terms of differential diagnosis, I know there's a lot of people talk about non-epileptic events.
00:15:51
Speaker
In the ICU, psychogenic seizures are probably less likely just because of the patient population.
00:15:59
Speaker
I'm sure that's a big part of what you evaluate outside of the ICU as a neurologist.
00:16:03
Speaker
But in the ICU, what would be among the differential diagnosis that you'd be thinking of?
00:16:09
Speaker
The problem or the difficulty with non-convulsive seizures is that many of them are related to underlying toxic metabolic encephalopathies.
00:16:17
Speaker
And I say that word knowing it's sort of a vague word we neurologists like to use, but I don't think anyone else likes to hear.
00:16:24
Speaker
But what I'm referring to there ultimately is the stuff that often impacts mental status.
00:16:30
Speaker
So I mentioned things like hyponatremia might precipitate seizures, but in the same token, they also precipitate an encephalopathy or an alteration in someone's level of arousal or attention.
00:16:40
Speaker
And so that overlap gives you a pretty broad differential to these folks.
00:16:46
Speaker
And I think that's where kind of starting the process by saying, I think this is what we're seeing.
00:16:51
Speaker
I think this could be seizures.
00:16:53
Speaker
And initiating that very first diagnostic workup with a pretty broad differential in mind, getting labs, getting a CT, moving to an EG when you can, kind of covers that spectrum to give you the idea of, well, here are the things that could be impacting their mental status.
Continuous EEG: Impact and Innovations
00:17:09
Speaker
now here's our definitive test to show whether they are doing that because in part seizures are present or whether they're doing that on their own.
00:17:18
Speaker
It's just a background encephalopathy.
00:17:21
Speaker
Perfect.
00:17:22
Speaker
Let's talk about treatment, Brandon.
00:17:24
Speaker
And my first question regarding treatment is, do all seizures in the ICU require anti-epileptic drug therapy?
00:17:32
Speaker
In general, probably.
00:17:36
Speaker
I think with seizures being sort of this situation,
00:17:41
Speaker
fever in a way from any patient, right?
00:17:43
Speaker
These are these are coming out because the brain is saying I am injured.
00:17:46
Speaker
But the problem with seizures is that they also tend to exacerbate injury or create injury independently of what was causing them to begin with.
00:17:57
Speaker
And there's been a lot of really good literature that that
00:18:01
Speaker
you know, looking at seizures in the brain in conjunction with other physiology, they are really impacting those neurons by outstripping their supply and demand matching.
00:18:12
Speaker
They're creating so much metabolic demand in those regions that are seizing, those neurons actually can begin to die back.
00:18:19
Speaker
And so even if we say, well, this is a symptom, this is an epic phenomenon even of this patient's underlying sepsis and systemic inflammation,
00:18:30
Speaker
you still have to get control of the seizures because in and of themselves, they may be causing additional harm.
00:18:36
Speaker
So in general, when we see seizures, we tend to try to treat them as best we can with the minimum amount of treatment that we can get away with that's effective.
00:18:46
Speaker
It's the effectiveness though, that we really want to focus on.
00:18:49
Speaker
Can we get them under control?
00:18:50
Speaker
Can we stop them?
00:18:52
Speaker
And once we've done that, then we can move forward with trying to mitigate their underlying cause.
00:18:56
Speaker
Perfect.
00:18:57
Speaker
And I guess another way of asking the same question would be that if you have a very transitory and identified cause, it doesn't necessarily mean that that patient will be condemned to antipoleptic therapy for years to come, right?
00:19:13
Speaker
So I think acutely, because of the factors you mentioned and the impact it has on neurons and potential morbidity, you want to take control and treat them properly.
00:19:23
Speaker
but then probably with neurology kind of figure out, okay, this is what we think happened.
00:19:27
Speaker
This is what the long-term plan would be outside of the ICU.
00:19:31
Speaker
Right.
00:19:32
Speaker
And I think that's a really, really important point.
00:19:34
Speaker
There have been a couple of institutions that have put in place these post-acute symptomatic seizure clinics that are designed to sort of see these patients after they've left the ICU in the hospital.
00:19:45
Speaker
Because while the incidence of epilepsy, and that's a diagnosis that requires unprovoked seizures, so after you've gotten out of the ICU, the acute brain injury or the acute systemic illness is over,
00:19:57
Speaker
You know, the incidence of epilepsy may be high, but still 40% or so of these patients are kept on anticonvulsants, sometimes many of them, probably far longer than they actually should
Future Directions in Seizure Management
00:20:09
Speaker
be.
00:20:09
Speaker
When you have something that's an acute symptomatic seizure, that means it's a symptom of what's happening acutely, right?
00:20:15
Speaker
And so when you take away that nidus that was creating the proclivity to have seizures, it's
00:20:22
Speaker
You know, in the majority of people, actually, you don't end up developing unprovoked seizures later down the line.
00:20:29
Speaker
So they're really there to treat that acute seizure problem and not necessarily to treat epilepsy, which is not a diagnosis they're going to get if they're in the middle of an acute illness that might be creating the seizures in and of itself.
00:20:44
Speaker
Perfect.
00:20:45
Speaker
Let's talk a little bit about if you get called to the bedside or somebody comes into the ED with what appears to be convulsions and make a diagnosis of seizure.
00:20:56
Speaker
What's the initial treatment in those cases?
00:20:59
Speaker
Depends on the type.
00:21:01
Speaker
And this can be a bit challenging because it's nuanced.
00:21:04
Speaker
But
00:21:05
Speaker
I think from a general intensive care sort of perspective, if you've got someone who's having motor manifestations, in other words, convulsions, if you see someone with GTCs, right, classic GTCs, so someone is having motor movements all over.
00:21:22
Speaker
We actually have good class one evidence that the first line of defense is a benzodiazepine.
00:21:27
Speaker
at an adequate dose and what i mean by that is uh for most adults more than more more than 40 kilos in size that's four milligrams of ativan or 10 milligrams of midazolam and you give that as quick as you can that's class one evidence where it gets nuanced is what i mentioned earlier in that most icu patients are having focal seizures they're not happening all over the brain necessarily and more importantly they're non-convulsive
00:21:54
Speaker
So it's a little bit different.
00:21:55
Speaker
We don't know how long they've been having these seizures.
00:21:58
Speaker
We're not sure if they're really spreading all over, staying in one spot.
00:22:03
Speaker
And so in many of our patients, we extrapolate this idea of benzodiazepines, and that's not inappropriate.
00:22:08
Speaker
I think it's still a good and efficacious first line of therapy, especially in our patients who already have a protected airway.
00:22:17
Speaker
There's absolutely no reason to start with a good dose of a benzodiazepine.
00:22:22
Speaker
as an abortive treatment for the seizures that you're seeing.
00:22:27
Speaker
The other piece of it though is that patient population where their airway is not secure, they're altered or they're encephalopathic in some way, and benzodiazepines may cause more harm than good.
00:22:39
Speaker
There's an old study that demonstrated that particularly in elderly people treated with benzodiazepines on a floor that it may increase mortality.
00:22:47
Speaker
And so those are patients where you step back and you say, okay, this is not a generalized tonic-clonic seizure where we have good class one evidence for how to treat this.
00:22:55
Speaker
This is a non-convulsive, often focal seizure.
00:22:59
Speaker
And if the treatment is worse than the disease, in other words, if we give a benzodiazepine, that patient comes to you for an airway watch, right, or needs an airway.
00:23:09
Speaker
we might need to change tack a little bit.
00:23:11
Speaker
And so that's where other medications that are fast-acting and known to be efficacious might be helpful.
00:23:19
Speaker
And that's often a situation where it gets a little bit tricky, but some of the things that you can do include things like fast-acting, intravenous anti-seizure drugs.
00:23:28
Speaker
Often we use Keppra, Rivaracetam is another one.
00:23:32
Speaker
that is pretty quick acting and non-sedating.
00:23:34
Speaker
Depakote actually has some pretty good evidence too.
00:23:36
Speaker
None of those actually will cause respiratory compromise.
00:23:41
Speaker
And then another trend that's come in the age of ketamine, which treats everything, is a low-dose ketamine, something you might use for pain, like 0.3 to 0.5 mix per gig as a bolus, can be a good abortant without respiratory depression too.
00:23:55
Speaker
So there's quite a bit you can use in the ICU patient
00:23:59
Speaker
Without an airway, you want to treat or abort those seizures.
00:24:02
Speaker
In general, if you remember benzos at an adequate dose, though, in general, you'll be in good shape for an initial treatment of seizures in those patients.
00:24:12
Speaker
One other, I think, point to make, though, is benzos wear off.
00:24:16
Speaker
in recurrence of seizures and status epilepticus is really common.
00:24:20
Speaker
So it's always prudent to chase it with a standard anticonvulsant.
00:24:26
Speaker
So if you're an antiseizure drug, if you're treating with a benzo as your first line, and again, that's an appropriate thing to keep in your mind to keep it simple, right?
00:24:35
Speaker
you always want to chase it with an anti-seizure drug to prevent recurrence when that benzo kind of filters out of their system.
00:24:41
Speaker
And so oftentimes we'll use that IV anti-seizure drug, of which there are many, but any one you pick is probably fine to start.
00:24:51
Speaker
And then you can kind of take it from there to see if that's going to be efficacious over the next coming hours.
00:24:57
Speaker
And you did mention, obviously, when you talked about benzos, the respiratory depression, and a lot of times these patients might have an airway already.
00:25:06
Speaker
But also, I think a common problem is that we underdose these and that patients really with seizures probably need a good dose.
00:25:16
Speaker
Is that something you can comment on?
00:25:19
Speaker
The efficacy that's been shown for the benzodiazepines is definitely predicated on a bigger dose than I think we tend to use.
00:25:28
Speaker
For a lot of the indications in the general ICU, we'll use smaller doses of Ativan, 0.5, 1, maybe 2.
00:25:35
Speaker
And for a lot of patients with seizures and satis epilepticus, most people will use these lower doses of Ativan, like 2 milligrams.
00:25:42
Speaker
But what's been shown in the randomized control trial literature, and again, this was generalized tonic-clonic status, right?
00:25:48
Speaker
But what was shown is that the doses that are required are more like four milligrams of lorazepam or 10 milligrams of bedazolam.
00:25:57
Speaker
So it seems like a lot, but when it comes to seizures, you really have to suppress those brain networks that are activated by the seizure and
00:26:04
Speaker
precipitating or propagating those seizures.
00:26:07
Speaker
That takes quite a bit.
00:26:09
Speaker
Undertreatment is something that the observational literature has been pretty clear about is associated with a lack of seizure control amongst other patient-centered outcomes in the hospital, like length of stay and mortality, even in some situations.
00:26:24
Speaker
Perfect.
00:26:25
Speaker
Another situation that I wanted to ask you about is patients with known epilepsy that are admitted to the ICU, perhaps with other diagnoses, and now they're intubated, they're NPO.
00:26:37
Speaker
Any specific considerations that we should have in managing these patients?
00:26:42
Speaker
The thing that I come across probably the most is that the patient who's in the ED and they have epilepsy and they're on meds and they have to stay in the ED because we just don't have beds.
00:26:54
Speaker
And hopefully you guys don't have to deal with that, but I'm sure everyone does.
00:26:58
Speaker
And so they might get intubated, they're sick, they're waiting on that bed and they just don't get their meds.
00:27:06
Speaker
And that's a problem.
00:27:07
Speaker
Those people develop their epilepsy, their seizures, and often they can become refractory and develop into status epilepticus.
00:27:15
Speaker
And so the biggest thing is to keep these epilepsy patients on the drugs they're on if you can.
00:27:21
Speaker
That may require placing in oral access and giving them the drugs, even if they're someone who you might not otherwise feed.
00:27:31
Speaker
such as if they're on high doses of levofed, they still need the drugs.
00:27:34
Speaker
That's really, really important.
00:27:36
Speaker
And if they do develop seizures, often optimizing the drugs they're already on makes an easy decision.
00:27:42
Speaker
If they're already on, say, phenytoin, it's worked for them for years, even though I'm not a big fan of phenytoin in the acute seizure setting, that's a nice tool to use.
00:27:52
Speaker
You can optimize those levels or optimize that dose.
00:27:55
Speaker
When it comes to giving them, you know, I think new drugs, then it becomes a little bit more challenging.
00:28:00
Speaker
But a lot of our IV anti-seizure drugs have been made in such a way that they actually don't interact all that much.
00:28:07
Speaker
Our newer anti-seizure drugs that are intravenous, things like Keppra, Licosamide, and Ribiracetam, these kind of medications tend to be pretty easy to add on top of.
00:28:19
Speaker
the seizure drugs that patients might be on, even the complicated ones in refractory epilepsy patients.
00:28:24
Speaker
But getting their drugs to them on time and avoiding that break, that delay that often will lower their seizure threshold, that is just the most crucial thing you can do.
00:28:35
Speaker
Perfect.
00:28:36
Speaker
Let's talk a little bit about status.
00:28:38
Speaker
We did mention it earlier.
00:28:41
Speaker
And could you just define for us, Brandon, what is status epilepticus?
00:28:48
Speaker
It, in some ways, depends on the type, again, in terms of what you would call status epilepticus.
00:28:55
Speaker
In the generalized tonic-clonic seizure world, the status epilepticus is really defined as based on two different time points.
00:29:06
Speaker
One is, when is that
00:29:08
Speaker
seizure going to stop and at what point does it seem like it's not going to stop.
00:29:13
Speaker
And so status epilepticus and someone who's got generalized motor seizures, if they last longer than five minutes, the likelihood that they are going to stop or remit long enough for that patient to begin having recovery is very, very low.
00:29:28
Speaker
And so we define status epilepticus in that case as a seizure lasting longer than five minutes.
00:29:34
Speaker
In patients with focal seizures, that time extends out a little bit to 10 minutes or so of continuous or recurrent seizure activity.
00:29:45
Speaker
And then when you have a patient with non-convulsive seizures, again, is what most of what we deal with in the ICU,
00:29:51
Speaker
What's been defined more recently, and this is in some ways based on some literature from the pediatric intensive care world, a seizure burden that is higher than 20% of your 30 or 60 minute recording would be considered status epilepticus.
00:30:08
Speaker
And again, it's just electrographic, right?
00:30:09
Speaker
So we don't see anything clinically.
00:30:11
Speaker
but more than 20% of your EG recording with seizures, whether recurrent or continuous, would be considered status epilepticus.
00:30:20
Speaker
I think the bottom line sort of conceptually is this.
00:30:22
Speaker
If you're having a seizure and it is very unlikely to stop on its own, or recurrent seizures and they're very unlikely to stop or abate on their own, that's status epilepticus.
00:30:33
Speaker
And is there a distinction between status and refractory status epilepticus?
00:30:39
Speaker
It's sort of a derivative difference in the sense that we define it based on the response to medications.
00:30:47
Speaker
So refractory status epilepticus is those patients who have failed not only a first line, again, which tends to be a benzodiazepine, but you've given them that IV ant, a seizure drug, or you've given them that bolus of whatever medication you're giving to abort seizures, and that has failed too.
00:31:05
Speaker
So if you've failed an abenzodiazepine in a second line,
00:31:08
Speaker
Now you're in what's called refractory status epilepticus.
00:31:12
Speaker
Perfect.
00:31:13
Speaker
And could you give us a little bit more of an outline of how you would deal therapeutically with status epilepticus?
00:31:20
Speaker
You talked about first line, second line, there's anesthetics, but just in general, what would be like a overall approach that would be based on current evidence?
00:31:33
Speaker
Current evidence.
00:31:34
Speaker
Yeah.
00:31:36
Speaker
where there's evidence that's being developed, certainly.
00:31:39
Speaker
And we've got a lot of observational data, but there's still a lot of debate.
00:31:44
Speaker
And I think the first thing to do is make a distinction.
00:31:48
Speaker
And that is between a patient who's got generalized seizures, so their entire brain is seizing, and patients who have focal seizures that aren't stopping.
00:32:01
Speaker
And the reason I'm making this distinction is
00:32:03
Speaker
is there's been an increasing amount of literature that suggests that anesthetics have an independent association with poorer outcome in patients who do develop status epilepticus.
00:32:16
Speaker
And so there's a risk benefit there that needs to sort of take into account the underlying type of seizure.
00:32:22
Speaker
Most of our seizures in the ICU are not going to be this.
00:32:27
Speaker
But when we think of status epilepticus in the literature or when we think of it conceptually, we often do think of a generalized or a whole brain seizure that's causing someone to have giant motor movements, tonic and clonic motor movements.
00:32:40
Speaker
So those patients who have that, that's a medical emergency.
00:32:43
Speaker
That's equivalent to a stroke, an MI.
00:32:46
Speaker
That is something that people are going to jump on.
00:32:47
Speaker
And that tends to be jumped on in the ED space, right?
00:32:51
Speaker
That's something that first responders are dealing with generally.
00:32:54
Speaker
And that's going to be a benzodiazepine, a second-line antiseizure drug, an intravenous antiseizure drug, whether it's Keppra or Depakote or phenytoin, which have been tested and are equivalent in aborting that status epilepticus.
00:33:07
Speaker
And then very quickly, within about an hour, certainly about 30 minutes to an hour, you should be starting an anesthetic continuous infusion in order to get that status under control.
00:33:20
Speaker
So it's a very rapid sequence algorithm.
00:33:23
Speaker
Many people don't have seizure protocols or status epilepticus protocols, but it's something that probably should be protocolized if you don't already have one.
00:33:29
Speaker
There's some out there published or on websites from institutions such as Yale University where I've got some colleagues and they've got terrific status epilepticus algorithms that flow very quickly.
00:33:41
Speaker
Again, that's generalized whole brain status.
00:33:44
Speaker
Benzo, second line IV anesthetic or anti-seizure drug anesthetic.
00:33:50
Speaker
In our patients in the ICU, it's that other population.
00:33:54
Speaker
It's generally focal seizures.
00:33:56
Speaker
They may spread, but they tend to be non-convulsive as well.
00:34:02
Speaker
And when it comes to that treatment, I think you've got a little bit more time to avoid anesthetics if you can.
00:34:12
Speaker
And what I mean by that is typically we'll give an abortant, meaning usually a benzodiazepine, think benzodiazepine first.
00:34:18
Speaker
We'll give an IV anti-seizure drug.
00:34:21
Speaker
And then we've got a minute to stop and say, is this working?
00:34:24
Speaker
Take that 30 to 60 minute period.
00:34:26
Speaker
They're focal seizures.
00:34:28
Speaker
We've just given an IV anti-seizure drug.
00:34:30
Speaker
Evaluate it first.
00:34:32
Speaker
This isn't generalized tonic-clonic status.
00:34:34
Speaker
You've got the luxury of a little bit more time to see if what you gave is working.
00:34:39
Speaker
And things like IV Keppra that we use all the time, or IV levotiracetam, tend to take 30 or 45 minutes to get into the system to saturate the receptors.
00:34:48
Speaker
So you have the time to give it that time and see if it's working.
00:34:51
Speaker
And if not, we'll often get a third IV antiseizure drug, maybe with another bolus of benzodiazepines, before moving on to anesthetics.
00:35:02
Speaker
And that's the patient with a protected airway where you can ramp the stuff up pretty quickly and you want to.
00:35:08
Speaker
But in the patient who's got a preserved mental status or airway, their vital functions are maintained.
00:35:14
Speaker
We'll often try to stepwise increase or optimize our antiseizure drugs, adding one at a time and evaluating its effect as long as their vital functions are preserved.
00:35:26
Speaker
And that's someone who we really want to avoid having to go down the road of intubation and anesthesia, if we at all possibly can.
00:35:34
Speaker
So there's a bit of nuance there, but separated in your minds, generalized motor tonic-clonic status, get that under control within an hour, anesthetics approved, they're going to be intubated, get it done.
00:35:47
Speaker
And focal and non-convulsive seizures and status.
00:35:51
Speaker
try to get things under control with an antiseizure drug, avoiding anesthetic until you really don't have a choice.
00:35:56
Speaker
You've failed one, maybe two antiseizure drugs.
00:35:59
Speaker
You're still seizing.
00:36:00
Speaker
Your vital functions are affected.
00:36:03
Speaker
Then that's a person you might consider anesthetic.
00:36:07
Speaker
So while that nuance is there, I think for the intensivist, the main thing to consider is really working closely with whoever's reading your EG to know whether that drug is working or not.
00:36:18
Speaker
If you can avoid anesthetics, do so, but know that it's in your back pocket if you really need to knock that out because those seizures are having impact on your patient.
00:36:27
Speaker
And obviously, once we get to the realm of anesthetics, I mean, that's going to be more prolonged treatment.
00:36:31
Speaker
And then the weaning would hopefully occur very slowly.
00:36:35
Speaker
And the idea being that you're giving the antipoleptics enough time to get to critical levels to control the seizures.
00:36:43
Speaker
Exactly, exactly.
00:36:46
Speaker
Could you tell us in simple words for a non-neurologist, what do we mean by birth suppression and why is that so important?
00:36:54
Speaker
Birth suppression is a pattern that you see on an EEG in which the brain waves, the squiggly lines, I can say squiggly lines, that's okay, like you say it, it's all right, right?
00:37:05
Speaker
The squiggly lines on the EEG happen for a period of maybe a couple of seconds and then there's a complete flat line on the EEG.
00:37:15
Speaker
for a number of seconds thereafter, followed by more squiggly lines.
00:37:19
Speaker
So it's a burst of electrical activity within the brain, followed by a flattening attenuation of suppression of the brain activity, and then you get another burst, burst suppression.
00:37:30
Speaker
In general, burst suppression is not a good thing.
00:37:34
Speaker
Burst suppression, for instance, in the OR is associated with long-term morbidity and mortality.
00:37:40
Speaker
in the literature from the anesthesia world.
00:37:44
Speaker
But the reason why it's used in this disease process is it's really a way of reducing the metabolic rate and the continuous organized activity of the brain, which sometimes is necessary to disrupt the seizures themselves.
00:37:58
Speaker
Those seizures are predicated on just a vicious cycle that continues them or propagates and keeps them going.
00:38:07
Speaker
And when you induce something like birth suppression, that tends to be enough to disrupt that seizure focus and finally allow the brain to sort of stop seizing.
00:38:21
Speaker
So really, it's kind of like a surrogate for a certain level of medication-induced coma that we hope helps stop the seizures.
00:38:32
Speaker
But the squiggly lines could be seizures or not, right?
00:38:36
Speaker
There are times when the bursts are highly epileptiform, it's true, and you see kind of a snapshot of what the seizures look like, even within the bursts.
00:38:44
Speaker
So as soon as the brain has any activity at all, it tends to look like the seizure that you were seeing.
00:38:50
Speaker
And that's a tough situation because often that's predictive that coming off the anesthetics, which we want to do as quickly as we can,
00:38:59
Speaker
may not work.
00:39:00
Speaker
In other words, we might wean those anesthetics and the seizures just come right back.
00:39:05
Speaker
And often we want to see those bursts look very boring, non-sharp, non-epileptiform.
00:39:12
Speaker
So it's something to look for.
00:39:14
Speaker
But when seizures or a seizure-like pattern that you're seeing lasts less than 10 seconds,
00:39:20
Speaker
While, you know, it's sort of it's a brief seizure functionally, we don't consider those to be seizures or they have another term that's being used to describe them.
00:39:30
Speaker
Brief potentially hyptal rhythmic discharges or birds.
00:39:34
Speaker
And they're really predictive more than anything else.
00:39:39
Speaker
but that means we have at least broken up those long, continuous periods of seizure activity.
00:39:46
Speaker
And by doing that, hopefully the brain supply and demand now are a bit better matched.
00:39:50
Speaker
That demand is not so much so that the neurons are becoming damaged as a result, or at least that's the idea.
00:39:56
Speaker
Still a lot of mystery surrounding birth suppression, how it works and whether it's the right target, quite frankly.
00:40:01
Speaker
Perfect.
00:40:02
Speaker
Perfect.
00:40:03
Speaker
And we did talk a little bit, obviously we already mentioned non-convulsive status, which is basically seizure activity in patients in the ICU specifically who are non-convulsive, are not having convulsions, but they're obviously encephalopathic and something that we want to treat as well.
00:40:21
Speaker
Is there a percent, a known percent of patients who start as convulsive that with treatment actually can deceive us without an EEG and we think, oh, they're better, but they're actually in non-convulsive status?
00:40:33
Speaker
Is that a real thing?
00:40:35
Speaker
Some really good kind of formative literature in that space was from a group from Rochester, Minnesota, who described seizures occurring in half of patients who stopped having motor seizures and status epilepticus that was still occurring in about one out of every 10 patients who stopped having motor seizures.
00:40:56
Speaker
So it's extraordinarily common.
00:40:57
Speaker
These patients are
00:41:00
Speaker
For all intents and purposes, I assume that they are still seizing if you've gotten control of their motor seizures.
00:41:06
Speaker
Okay, and I think that that really leads us to the next topic I wanted to ask you about, which is...
00:41:11
Speaker
a discussion around the ictal-interictal continuum and these patients that we're trying to figure out are there CEGN or not.
00:41:19
Speaker
And like you mentioned, the role in the ICU of continuous EEG has expanded dramatically, I would say, in the last decade.
00:41:27
Speaker
But when should we have continuous EEG in the ICU?
00:41:34
Speaker
Well, there's a variety of indications that have been
00:41:38
Speaker
endorsed by several societies, the American Clinical Neurophysiology Society and European societies.
00:41:48
Speaker
And they're all fairly consistent, although, you know, they acknowledge the level of evidence or, you know, the strength of the recommendation oftentimes is fairly weak.
00:41:58
Speaker
But I think there's a fair amount of consensus that patients who have a mental status that is abnormal and not explained by their exam or injury or excuse me, by their radiographic presentation or their injury is a population where you really want to get a continuous EG.
00:42:16
Speaker
One of the recommendations specifically is to get EEG in patients who have had motor seizures and have not recovered a normal degree of mental status, kind of presumed to what we were just talking about.
00:42:28
Speaker
And then there are other instances where, you know, patients who have
00:42:34
Speaker
odd movements, things that you don't really quite know what you're seeing, but they're twitching, they're moving, they're jerking, they're moving their eyes in a funny way.
00:42:43
Speaker
Believe it or not, those are things that also are potentially indications.
00:42:47
Speaker
So if you need to see what this spell, this movement is, you really need EEG to do that.
00:42:55
Speaker
And in many cases, these patients have these things, you know, randomly throughout a day.
00:42:59
Speaker
And so continuous EG is helpful because, you know, you'll capture that on the video.
00:43:04
Speaker
So those seem like pretty broad indications, and they are.
00:43:07
Speaker
And I think that leaves a lot of the decision making up to us as the intensivists to know that
00:43:14
Speaker
you know, whether this mental status this patient is displaying is expected or not.
00:43:20
Speaker
And that's a tall order.
00:43:22
Speaker
And I tend to fall in the camp of, well, if I'm not sure, you know, if I can get an EEG or at least do a point-of-care bedside EEG, I'll feel a lot more comfortable.
00:43:31
Speaker
And one of the, I guess, unintended consequences of expanding the use of EEG in the ICU is that we start finding in a lot of our patients, especially post-cardiac arrest or noxia
00:43:42
Speaker
brain injury patients, a lot of patterns that don't look normal, right?
00:43:46
Speaker
Like these PLEDs, BIPLEDs, GPLEDs.
00:43:51
Speaker
And I know there's been some literature looking at these.
00:43:55
Speaker
Could you talk a little bit about, I guess those are abnormal findings that are not necessarily seizures and what should we do about them?
00:44:04
Speaker
Oh, that's a big question.
00:44:05
Speaker
Pandora box has been opened.
00:44:08
Speaker
All right.
00:44:09
Speaker
So we have another hour and a half on this podcast.
00:44:12
Speaker
I'm kidding.
00:44:12
Speaker
So, uh, so for, for you intensivists in the audience, right?
00:44:17
Speaker
If you start using continuous EG, you're going to see a whole bunch of acronyms pop up on your EG report.
00:44:23
Speaker
Uh, and there's going to be a lot of abnormalities on the EGs that you're looking at.
00:44:28
Speaker
And that's just a fact that these are incredibly common patterns and they're very, um,
00:44:34
Speaker
They're very difficult to tease apart sometimes what they mean.
00:44:38
Speaker
And the acronyms that you tend to see are based on a standardized terminology for reading and reporting continuous EG that's been elaborated over the last 10 years or so.
00:44:47
Speaker
And basically what they're trying to describe are these things that are occurring on the EG where the brain is creating a rhythm or a pattern that is not what the brain is supposed to be doing.
00:44:58
Speaker
The brain doesn't do rhythms and patterns.
00:45:00
Speaker
The brain desynchronizes.
00:45:05
Speaker
And that tends to be then when you see something that's rhythmic or periodic, that tends to be an abnormal thing.
00:45:14
Speaker
So these acronyms that are used are things that refer to where the abnormality is happening and what it looks like.
00:45:22
Speaker
So the terms tend to be, or the most common terms tend to be lateralized periodic discharges or LPDs, generalized periodic discharges, and then there's rhythmic discharges or rhythmic delta activity as well.
00:45:37
Speaker
You'll see those quite a bit because it's the most common things we see.
00:45:41
Speaker
Here's the problem.
00:45:42
Speaker
When you have a seizure,
00:45:43
Speaker
If you were to look at it on the EG and describe it, you would say it looks a whole lot like supraventricular tachycardia.
00:45:51
Speaker
It's a very rapid, sharp, and slow wave discharge.
00:45:56
Speaker
When you look at something like lateralized periodic discharges, you'll go to the EG, and it looks a whole lot like normal sinus rhythm or maybe Y-complex QRSs.
00:46:10
Speaker
But it's slower, right?
00:46:11
Speaker
It's not SVT.
00:46:13
Speaker
and they're not evolving.
00:46:14
Speaker
In other words, they're not speeding up or slowing down, which is the characteristic that we look for in the electrophysiology world of seizures.
00:46:24
Speaker
So we're left with a question.
00:46:25
Speaker
These are slow, and they're not evolving.
00:46:28
Speaker
They're not fast enough to be seizures.
00:46:30
Speaker
They're not evolving like seizures do.
00:46:33
Speaker
And so we're left with a question of what they mean, and the literature has been
00:46:37
Speaker
It's varied in terms of how it approaches this, but I think the one thing we know is that when we see these things, that is brain that is likely to or has a proclivity to cease.
00:46:51
Speaker
So it is in and of itself a warning sign.
00:46:54
Speaker
This is a patient who has a higher likelihood that they're going to have a seizure.
00:46:59
Speaker
If you were to do a routine EG, because it's hard to get a continuous EG at your center, for instance, and you see one of these patterns,
00:47:08
Speaker
It looks like there's QRS complexes sitting there in your squiggly lines.
00:47:12
Speaker
That's someone who you probably want to convert over to a continuous EG based on what we were talking about before.
00:47:18
Speaker
It takes some time to have the relevant sensitivity to detect non-convulsive seizures.
00:47:24
Speaker
Those patients have a much higher incidence.
00:47:26
Speaker
Lateralized periodic discharges, for instance, if you have these
00:47:31
Speaker
epileptiform looking discharges coming from one side of the brain, right?
00:47:35
Speaker
If you were to see a QRS complex in just like one of those channels or those banks of channels, that's a patient who has a 40% likelihood, or I should say 40% of those patients go on to develop seizures.
00:47:51
Speaker
So it's much higher than what we've been talking about, you know, 10%, maybe 20%, depending on the population.
00:47:56
Speaker
And those are patients to watch a little bit longer.
00:47:58
Speaker
Now, the other problem,
00:47:59
Speaker
confusion or not confusion, I guess, complexity within the literature is that there are situations in which those patterns are actually seizures in and of themselves.
00:48:08
Speaker
They're not just a pattern that says this brain is irritable and ready to seize.
00:48:12
Speaker
They're actually that brain seizing, but it's just such an injured brain that those seizures are not propagating as quickly or as robustly as you would expect from a normal brain or a brain that's able to generate a normal seizure.
00:48:28
Speaker
And that gets really tricky.
00:48:29
Speaker
So a lot of times, you know, from my standpoint anyway, what I want to do is test this out.
00:48:35
Speaker
I want to know, is this pattern actually seizure?
00:48:39
Speaker
In other words, is it impacting this patient's brain to the point where what I'm seeing, a patient with altered mental status or coma, is being impacted by this?
00:48:50
Speaker
And the only way to test that is by getting rid of that pattern, just like you would treat a seizure, to see if the patient gets better.
00:48:58
Speaker
And that's something that's been advocated for.
00:49:00
Speaker
We've actually studied it and you get a, actually a pretty robust number of patients, about 40% of patients who respond to getting rid of those abnormal discharges and they actually get better.
00:49:14
Speaker
And that tells you that these aren't just a risk factor for seizures, but they actually may be impacting your patient.
00:49:20
Speaker
So for the intensivist, if you see it heads up, that's someone who probably needs to be watched a little more closely and
00:49:26
Speaker
because they may develop seizures and it's an opportunity for you to actually go in and try to treat these things like you would seizures give them a benzodiazepine clean up the eg and then on the other side you can see whether that patient's actually doing better more awake right they shouldn't be if you give them two milligrams five milligrams of midazolam that patient should be asleep on you right but if all of a sudden they're able to follow a command they're able to open their eyes
00:49:55
Speaker
their language starts to get better maybe if they have an aphasia whatever the case may be whatever their symptom was if it's improving with the benzodiazepine because you've cleared out this abnormal pattern that may indicate they need to be treated more like seizures rather than a warning for the potential seizures that could develop but it's very complicated and a lot of people hate the term a lot of people hate seeing it not knowing what to do with it and so if you feel that way you're not alone
00:50:23
Speaker
as this could be one of these two problems and being proactive about trying to test that hypothesis, could these be seizures in and of themselves, gives you the power to actually kind of figure that out, tease it apart and know where to go from there.
00:50:36
Speaker
And I think that the bottom line is really that there's not one size fits all and that these require more investigation and sometimes some therapeutic trials to really see, I mean, is there an impact or not?
00:50:47
Speaker
If you treat them, like you said, and nothing happens, well, maybe that's not the route you want to go.
00:50:51
Speaker
But obviously, something that we have learned over the years as we find more and more abnormalities in our patients.
00:50:58
Speaker
So thanks for helping us give some clarity on what seems to be still a very nuanced and complex topic.
00:51:06
Speaker
The other question I had regarding this topic is the new technology that's emerging for continuous EEG.
00:51:14
Speaker
You mentioned some of them, Cerebel, Point of Care.
00:51:18
Speaker
Any comments on where those are headed and the role in non-neural ICUs?
00:51:27
Speaker
I think these things that are coming out that are really designed to be put in our hands as intensivists and our fellows residents hands, even, you know, in the hands of the folks working in the ED, I think these are a big sea change in some sense in terms of how we are approaching this problem in a really positive way.
00:51:49
Speaker
Yeah.
00:51:51
Speaker
And the reason I say that is because this, you know, from a neurology standpoint, you go down, you evaluate a patient, and then you say, here's the differential diagnosis.
00:51:59
Speaker
They could be having X, Y, Z, and seizures is one of the possibilities.
00:52:04
Speaker
Let's get an EG.
00:52:06
Speaker
And if it's your shop, you know how that works.
00:52:10
Speaker
It may be 9 o'clock the next morning when the tech arrives.
00:52:13
Speaker
It might be five hours later when your techs can get there, even in very robust epilepsy centers with continuous EG.
00:52:20
Speaker
It still takes two or three hours to hook somebody up.
00:52:24
Speaker
And that's fast because continuous EG takes a lot of work to glue on the electrodes properly and get things working properly.
00:52:33
Speaker
But within that two to three hour window, a lot of stuff happens.
00:52:36
Speaker
And I think that's where these technologies actually bridge a gap.
00:52:40
Speaker
They fit in the space between your exam and suspicion and differential and the diagnostic tests that you want to get to prove that hypothesis.
00:52:54
Speaker
And the importance of that is a couple of things.
00:52:56
Speaker
So one is it gives you the power to go down there and put this thing on and get an answer.
00:53:00
Speaker
And some of the technologies that are out there not only include a very user-friendly headband or head cap that can be placed by you, by your nurses, but some of them also include things like artificial intelligence algorithms that give you a readout.
00:53:16
Speaker
This is seizures.
00:53:17
Speaker
This is not likely seizures.
00:53:20
Speaker
And that's hugely important.
00:53:21
Speaker
A lot of us don't read EG.
00:53:23
Speaker
And so it becomes really important because you can diagnose things as you're seeing the patient.
00:53:28
Speaker
So I ask the residents and fellows if they have someone who you get called about, rule out status, or we have someone in the ICU who we want to know, like right now, are they in status?
00:53:38
Speaker
Grab the cerebral on your way to seeing the patient.
00:53:41
Speaker
That's your stethoscope.
00:53:42
Speaker
That's your reflex hammer.
00:53:43
Speaker
That's your neurological exam extended.
00:53:46
Speaker
And you can do that at the best while you're doing that exam.
00:53:48
Speaker
By the time you get done, you got an answer.
00:53:51
Speaker
You've been able to mark that off your differential or maybe put it higher on your differential depending on what you're seeing.
00:53:59
Speaker
So it's a really powerful thing.
00:54:01
Speaker
The other side of that coin, though, is not just getting treatment urgently and in the right patient rather than treating a patient with drugs that shouldn't be treated with those drugs or not treating a patient who then has seizures for the next two hours until you prove the point.
00:54:17
Speaker
But the patients who you don't see seizures on now can get triaged to an appropriate ICU, right?
00:54:25
Speaker
These are patients maybe that need to go to a medical ICU for sepsis.
00:54:29
Speaker
rather than a neurological ICU for presumed status epilepticus.
00:54:33
Speaker
And you can start getting rid of stuff that could be harmful.
00:54:36
Speaker
The patient who's been intubated and now they're on anesthetics and they've been ramped up because everyone's worried they're having seizures, you can take those off within the 15, 20 minutes it takes to examine that patient and get a bedside EEG rather than leaving them on for the two, three hours it might take you in a best case scenario to get your continuous EEG.
00:54:54
Speaker
So that gap being filled
00:54:57
Speaker
leads to a tremendous amount of clinical ramifications within that very, very short period of time, both in the ED and with our ICU consults, as well as in our ICUs proper.
00:55:09
Speaker
Excellent.
00:55:09
Speaker
And I think that clearly we're seeing these appear in more and more ICU.
00:55:13
Speaker
So learning how to use them, it sounds like they might be more sensitive than specific in terms of ruling out, like if it's normal, normal, right?
00:55:23
Speaker
Or there's an abnormality might trigger, I mean, more aggressive evaluation, but it can help you kind of navigate the initial treatment of these patients in a meaningful way, like you said.
00:55:34
Speaker
Yeah, absolutely.
00:55:35
Speaker
Yeah.
00:55:36
Speaker
The last question I have regarding seizures is when should we consider prophylaxis for seizures?
00:55:45
Speaker
The official guidelines right now are that we would, you know, the recommendations for seizure prophylaxis in patients with moderate severe traumatic brain injury for a period of seven days to treat just the acute symptomatic seizures that happen within that period of time.
00:56:06
Speaker
and they might be reasonable in patients with subarachnoid hemorrhage, particularly port grade subarachnoid hemorrhage.
00:56:11
Speaker
Those are the official recommendations.
00:56:13
Speaker
What I'll tell you is most people use prophylactic antiseizure drugs for patients with acute brain injuries in general, whether that's intracerebral hemorrhage, traumatic brain injury, subarachnoid hemorrhage, and postoperative patients who've undergone resection, for instance, of a brain tumor.
00:56:32
Speaker
for that same period of time extrapolating those recommendations for seven days of anti-seizure drugs to prevent the acute symptomatic seizures.
00:56:41
Speaker
Evidence is limited on that.
00:56:42
Speaker
Anti-seizure drugs aren't benign by any means, and they do have side effects.
00:56:47
Speaker
So, you know, it oftentimes is something that happens in conjunction with your neurosurgery colleagues who are often seeing these patients or your neurocritical care neurology colleagues who might be collaborating with you in their care.
00:56:59
Speaker
but oftentimes it's kind of site-specific or provider-specific.
00:57:02
Speaker
But those are the two populations where really the evidence is pretty clear or at least is robust enough that the recommendations officially are to prophylax those people.
00:57:12
Speaker
Perfect.
00:57:13
Speaker
Well, Brandon, is there anything that we didn't cover that you want to make sure our listeners are aware of?
00:57:21
Speaker
I think we covered a lot of ground.
00:57:23
Speaker
If anything, I think questions will probably come to mind, situations you've had
00:57:28
Speaker
that have some nuance we didn't really hit on.
00:57:31
Speaker
And so I think those are things to comment on, to put out to the community and think through.
00:57:37
Speaker
There's a lot of nuance here to this stuff, but at the same time, I think keeping things simple, right?
00:57:42
Speaker
Knowing these are frequent, knowing you can diagnose them, knowing that you can treat them is the most important thing to keep it in the front of your mind as you're taking care of the folks that you take care of.
00:57:54
Speaker
For sure.
00:57:55
Speaker
Well, we like to close every episode of the podcast with a couple of questions that tap into the wisdom of our guest unrelated to the clinical topic we discussed.
00:58:03
Speaker
Would that be okay?
00:58:05
Speaker
Sure.
00:58:06
Speaker
So the first question relates to books.
00:58:08
Speaker
Are there any books that have influenced you significantly or books that you have gifted often to other people?
00:58:16
Speaker
You know, I think that I probably watch Netflix too much and don't read enough.
00:58:24
Speaker
But one of the books I think that's been the most influential and that I, one of the few that I've read multiple times at this point is, is Hermann Assey's Siddhartha.
00:58:33
Speaker
Um, because, you know, it's such a simply written book and so beautiful and it has so much into it that you, you know, in it that you, you read something new every time.
00:58:45
Speaker
And so, and that's the book that I probably gifted the most, you know, a lot of what we do when we do it, right.
00:58:50
Speaker
I've heard people refer to it as intensive care.
00:58:52
Speaker
And I think that's, you know, it kind of has, uh, I think an ethos, that book, right.
00:58:57
Speaker
That you can apply it to your, to your practice, to your life.
00:59:00
Speaker
In fact, to, uh, to keep things simple, to be in the moment and to appreciate what we've got.
00:59:04
Speaker
Absolutely.
00:59:05
Speaker
And I think like you mentioned, it's a, uh,
00:59:08
Speaker
A short read, but very powerful.
00:59:10
Speaker
And one of those books that's worth rereading, right?
00:59:12
Speaker
That you come back after the years and find new things.
00:59:16
Speaker
So definitely we'll link that to the show notes.
00:59:19
Speaker
Interesting, you mentioned Netflix.
00:59:21
Speaker
I was reading earlier about culture in organizations and came upon the Netflix PowerPoint deck of their culture, which went viral several years ago.
00:59:34
Speaker
And I think I read that 17 million people have looked at it.
00:59:38
Speaker
It's a PowerPoint deck that's supposed to be read, not presented.
00:59:42
Speaker
But it talks about how Netflix shaped their culture to become what they became today.
00:59:47
Speaker
So we'll link that as well.
00:59:49
Speaker
I think it's something interesting.
00:59:51
Speaker
That is interesting.
00:59:52
Speaker
They've become so successful.
00:59:53
Speaker
It would be really interesting.
00:59:55
Speaker
Cool.
00:59:55
Speaker
The second question is, what do you believe to be true in medicine or life that most people don't believe or don't act like they believe?
01:00:04
Speaker
Oh, that's a good question.
01:00:05
Speaker
Because when I say it's the truth, you know, it doesn't mean it's actually a truth, I suppose.
01:00:10
Speaker
But something that I do think that, you know, probably don't, a lot of people don't, and I say and think a lot of things that a lot of people don't, is that, you know, in medicine anyway, I'm a diagnostician, I use a lot of tools, I have to, but the tools that I use are really only as useful as the person using them.
01:00:31
Speaker
And that's something that's kind of inflammatory.
01:00:34
Speaker
But I guess what I mean is I guess what I mean is it's not enough to simply possibly passively observe the things that we often will do to diagnose people that we do to try to to to get more information.
01:00:48
Speaker
We have to actually be active about what we're seeing.
01:00:51
Speaker
Cognitive anchoring often gets us stuck in ruts where we kind of sit back and say, well, this is what it is.
01:00:56
Speaker
We think this is what it is, right?
01:00:58
Speaker
And so it's cliche to say, and I think this is where I get into something a lot of people may not think of or do, but we should think different, obviously.
01:01:08
Speaker
That's a thing that we've
01:01:10
Speaker
I think had on, on Apple commercials for decades now, but doing so and using a scientific approach to test these hypotheses is really a privilege we have in the ICU setting.
01:01:21
Speaker
That's the truth in medicine.
01:01:23
Speaker
I think people don't think of, we are more, but we have this opportunity to test hypotheses in real time.
01:01:30
Speaker
Could it be this?
01:01:30
Speaker
Could it be that?
01:01:32
Speaker
If I do something diagnostic, let's intervene on it and see if it changes our diagnostics.
01:01:37
Speaker
Uh,
01:01:38
Speaker
That's something that I think is really important.
01:01:41
Speaker
And I hope people are starting to do.
01:01:44
Speaker
I hope people do and try to avoid things like getting stuck on a specific, you know, diagnosis, a specific situation that is maybe not adding up for that patient.
01:01:56
Speaker
I agree, and I think that the whole concept of intelligent failure is right.
01:02:00
Speaker
I mean, how can I get the most information with a minimal negative impact on my patient and allows me to say this is more likely to be it or this is definitely not it, right?
01:02:10
Speaker
But sometimes, I mean, that type of trials, like we mentioned, with the abnormal EEGs in some of these patients can give you a better answer.
01:02:20
Speaker
Totally.
01:02:20
Speaker
And that's life too.
01:02:21
Speaker
We always have to change tack, right?
01:02:22
Speaker
If something's not working, but I don't find a lot of people do that.
01:02:26
Speaker
I don't know why.
01:02:26
Speaker
So cognitive flexibility, it's the best thing ever.
01:02:29
Speaker
I like it.
01:02:30
Speaker
And the last question is what would you want every listener and intensivist to know could be about the topic.
01:02:38
Speaker
Something else could be a quote, specific fact, or just a thought.
01:02:43
Speaker
Well, as a neurointensivist, I think the thing that comes to mind when you ask that is when it comes to brain stuff, whether that's seizures and status epilepticus, of course, and all the other brain injuries we end up dealing with, the brain's a long game.
01:03:04
Speaker
And I think contrary to what a lot of us have said,
01:03:07
Speaker
learned or grown up with or maybe thought in our clinical practice, there is almost always something that can be done for patients with acute brain injuries, with seizures, with status epileptics.
01:03:21
Speaker
There's never really an excuse for nihilism in the majority of these patients.
01:03:25
Speaker
And it's very easy to get nihilistic about brain stuff.
01:03:28
Speaker
It's a long game, like I said.
01:03:30
Speaker
And so when it comes to these patients who have
01:03:34
Speaker
brain disorders, hope is really the best we've got, optimism, that you can do something and you can impact outcome in a positive way, even if it doesn't look that way on the ground at that moment at the bedside.
01:03:49
Speaker
Perfect.
01:03:49
Speaker
I think this is a good place to stop.
01:03:52
Speaker
Brandon, thank you so much for sharing your expertise and your time with us.
01:03:56
Speaker
I hope to have you back on the podcast to discuss other neurocritical care topics and look forward to seeing you in person soon.
01:04:03
Speaker
I really appreciate you having me on, Sergio.
01:04:04
Speaker
Thanks so much for the opportunity.
01:04:06
Speaker
And I hope to see you soon as well.
01:04:09
Speaker
Thank you for listening to Critical Matters, a sound podcast.
01:04:12
Speaker
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01:04:18
Speaker
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01:04:23
Speaker
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