Does this patient have seizure?
Focal or generalized seizure
Dialysis disequilibrium syndrome
Hard water syndrome (high calcium or magnesium in dialysate)
Cerebrovascular accident (ischemic or hemorrhage)
Malignant hypertension (hypertensive encephalopathy)
Cerebral anoxia due to sustained hypotension
Suboptimal anti-convulsant plasma level (removed during dialysis)
Acute aluminum intoxication
Drug-induced neurotoxicity (theophylline, meperidine, and anti-microbial agents [e.g., penicillin, cefepime, imipenem
What tests to perform?
Laboratory tests should be ordered to identify causes
Blood glucose to exclude hypoglycemia
Serum sodium to exclude hyponatremia
Serum calcium to exclude hypocalcemia or hypercalcemia
Serum magnesium to exclude hypomagnesemia
Neuro-imaging study (CT scan or MRI) should be obtained to exclude intracranial pathology especially in the setting of focal or refractory seizures
Electroencephalography and lumbar puncture may be required
How should patients with seizure be managed?
Maintain airway patency and protection (in case of prolonged postictal state)
Intravenous benzodiazepine such as lorazepam (first choice), diazepam, and midazolam
Intravenous phenytoin if uncontrolled by benzodiazepine
Intravenous 50% dextrose in water if hypoglycemia is suspected
Identify causes and correct causes
What happens to patients with seizure?
Need for hospitalization
Risk of aspiration pneumonitis
Risk of permanent neurological damage (especially in status epilepticus)
How to utilize team care?
1. Specialty consultations – Neurologist
2. Nursing – Close monitoring of high-risk patients with frequent neurological assessment
Are there clinical practice guidelines to inform decision making?
2013 updated evidence review of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes (Published by The International League Against Epilepsy, ILAE)
Limitations: Focused on long-term efficacy as initial monotherapy for patients with newly diagnosed or untreated epilepsy (not dialysis patients).
ICD-10-CM diagnosis code R56.9: Unspecified convulsion
What is the evidence?
Glauser, T, Ben-Menachem, E, Bourgeois, B, Cnaan, A, Guerreiro, C, Kälviäinen, R, Mattson, R, French, JA, Perucca, E, Tomson, T. “ILAE Subcommission on AED Guidelines. Updated ILAE evidence review of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes”. Epilepsia. vol. 54. 2013. pp. 551-63.
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