How do you manage seizures in post-cardiac arrest patients who are intubated (intubation)

From the Guidelines

Management of seizures in post-cardiac arrest intubated patients requires prompt recognition and treatment with antiepileptic medications, with first-line therapy typically including intravenous benzodiazepines such as lorazepam or midazolam, followed by loading doses of antiepileptic drugs like levetiracetam or valproic acid, as recommended by the most recent guidelines 1. The treatment of seizures in post-cardiac arrest patients is crucial to minimize secondary brain injury and improve chances of neurological recovery.

• First-line therapy typically includes intravenous benzodiazepines such as lorazepam (4 mg IV) or midazolam (5-10 mg IV) 1.
• Loading doses of antiepileptic drugs like levetiracetam (60 mg/kg, up to 4500 mg) or valproic acid (40 mg/kg) are also recommended 1.
• For refractory seizures, continuous EEG monitoring should be initiated, and escalation to anesthetic agents may be necessary, including propofol (1-2 mg/kg bolus, then 30-200 mcg/kg/min) or midazolam infusion (0.2-0.6 mg/kg/hr) 1.
• Targeted temperature management at 32-36°C should be considered as it may reduce seizure burden 1.
• Underlying causes such as electrolyte abnormalities, hypoxia, or metabolic derangements should be corrected simultaneously 1.
• Continuous EEG monitoring is essential for at least 24-48 hours to detect non-convulsive seizures, which are common in this population 1. The most recent guidelines recommend treating seizures in post-cardiac arrest patients, despite the lack of high-level evidence, as untreated clinically apparent seizure activity is thought to be potentially harmful to the brain 1.
• The TELSTAR trial, a randomized clinical trial, found that protocolized tiered treatment targeting suppression of EEG rhythmic or periodic patterns did not differ in rates of poor neurological outcome compared to standard of care 1.
• However, patients with unequivocal electrographic seizures or evolving patterns may fare better with protocolized, tiered antiseizure treatment 1. It is essential to note that the management of seizures in post-cardiac arrest patients should be individualized, and the treatment approach may vary depending on the patient's specific condition and response to treatment.
• The use of sedatives and antiepileptic drugs should be carefully considered, as they can have significant side effects and interact with other medications 1.
• The choice of sedative agent, such as fentanyl, propofol, or dexmedetomidine, should be based on the patient's clinical status and the potential risks and benefits of each agent 1.

From the Research

Managing Seizures in Post-Cardiac Arrest Patients

To manage seizures in post-cardiac arrest patients who are intubated, several strategies can be employed:

• Medication administration: Intravenous lorazepam and levetiracetam can be used to immediately cease seizures, as seen in a case report where these medications resulted in the cessation of repetitive electrographic seizure activity 2.
• Therapeutic hypothermia: This treatment can be used to optimize neurological recovery, as mentioned in a study on post-cardiac arrest syndrome 3.
• Brain multimodality monitoring: This method can be used to evaluate secondary brain injury associated with seizure activity after cardiac arrest, allowing for more targeted treatment 2.
• Intensive care support: A coordinated approach involving various medical specialties is necessary for managing post-cardiac arrest syndrome, including seizure control and management of hyperglycemia 3.

Post-Cardiac Arrest Care

Post-cardiac arrest care involves several key components, including:

• Minimizing CNS injury: This can be achieved through targeted temperature management, neuroprognostication, and other strategies 4, 5.
• Managing cardiovascular dysfunction: Vasoactive support may be necessary to overcome transient myocardial dysfunction, and referral for urgent angiography and percutaneous coronary intervention should be available if appropriate 3, 6.
• Reducing systemic ischemic/reperfusion injury: This can be achieved through optimized ventilation, circulation, and other treatments 4, 6.
• Identifying and treating the underlying cause: This is crucial for preventing further injury and promoting recovery 4, 5, 6.