1. Which benzodiazepine do you prefer for the treatment of status epilepticus (SE)? Which do you prefer for pediatric patients?
2. Which second-line agents do you use for treatment of SE?
3. In which adult patients with first-time seizure do you obtain emergent imaging?
4. How do you diagnose pseudoseizure?
EM Lyceum 
1. Adult: Midazolam 10 mg IM, Peds: Lorazepam 2-4 mg IM
2. keppra 500 mg iv
3. Traumatic/infectious/space occupying suspect
4. eyes closed, pelvic thrusting, no postictal state
1.) lorazepam and lorazepam 2.) phenytoin or fosphenytoin 3.) all unless obvious etiologic metabolic agent 4.) multiple ways: purposeful movements, ammonia ampule, no postictal state
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1. Ativan and Ativan. 2. Keppra 3. All unless clear cut explanation. 4. Look for atypical characteristics understanding that there still is overlap between “true” and “pseudo” seizure
1. Benzo of choice: Midazolam if no IV access, Lorazepam IV (though Diazepam a good alternative). 2. Phenobarb under 1 year, Dilantin after one year. Though Keppra probably a better alternative when it becomes more readily available. 3. When I’m concerned about infection, trauma or space occupying lesions. 4. Pseudo seizures and the”Arm Drop Test” if history consistent with pseudo vs real, Breath holding spells. Reflux in babies (Sandifer’s). ALTEs
1) IM midaz if no access. if access, escalating Ativan doses. No evidence for more recurrence with midaz despite “it wearing off quicker.”
2) Keppra 1-2g loading over 5-10 minutes (somewhat off label, but good evidence for rapid load without ADRs). or Depakote, which seems to work best in meta-analysis. Phenytoin takes too long to load, and cerebryx causes too many issues (load enough patients with cerebryx and you’ll see patients so dizzy they cant walk after and go hypotensive.)… Basically, the longer you wait, or the more you give low doses of benzos (2mg or less of ativan at a time) and delaying second anti-epileptic forces you to go propofol. Do I get credit for the boards for saying vitamin B6? Hypertonic saline if you’re lucky enough to do a POC sodium.
3) new onset seizure over age… 40? anyone with focal deficits or trauma, or immunocompromised / infection concern.
4) arm drop test? no post-ictal state? or perhaps this: https://www.youtube.com/watch?v=Q6sRyrB_UMA
1. Benzodiazepine. If iv access plus, go for Lorazepam 0.1mg kg. Midazolam if no IV access. Nice drug to give IM, IN or buccal
2. AED. Phenytoin Na 20mg kg
3. Anaesthetic agents. Phonobarb or TPS. Propofol is an option but need to be cautious with higher infusion rates. Can develop PIS.