7.If seizures persist, intubate the patient and give:

-Midazolam (Versed) 0.2 mg/kg IV push, then 0.045 mg/kg/hr; titrate up to 0.6 mg/kg/hr OR

-Propofol (Diprivan) 2 mg/kg IV push over 2-5 min, then 50 mcg/kg/min; titrate up to 165 mcg/kg/min OR -Phenobarbital as above.

-Induce coma with pentobarbital 10-15 mg/kg IV over 1-2h, then 1-1.5 mg/kg/h continuous infusion. Initiate continuous EEG monitoring.

8. Consider Intubation and General Anesthesia Maintenance Therapy for Epilepsy:

Primary Generalized Seizures – First-Line Therapy:

-Carbamazepine (Tegretol) 200-400 mg PO tid [100, 200 mg]. Monitor CBC.

-Phenytoin (Dilantin) loading dose of 400 mg PO, followed by 300 mg PO q4h for 2 doses (total of 1 g), then 300 mg PO qd or 100 mg tid or 200 mg bid [30, 50, 100 mg].

-Divalproex (Depakote) 250-500 mg PO tid-qid with meals [125, 250, 500 mg].

-Valproic acid (Depakene) 250-500 mg PO tid-qid with meals [250 mg].

Primary Generalized Seizures -- Second Line Therapy:

-Phenobarbital 30-120 mg PO bid [8, 16, 32, 65, 100 mg]. -Primidone (Mysoline) 250-500 mg PO tid [50, 250 mg]; metab-

olized to phenobarbital.

-Felbamate (Felbatol) 1200-2400 mg PO qd in 3-4 divided doses, max 3600 mg/d [400, 600 mg; 600 mg/5 mL susp]; adjunct therapy; aplastic anemia, hepatotoxicity.

-Gabapentin (Neurontin), 300-400 mg PO bid-tid; max 1800 mg/day [100, 300, 400 mg]; adjunct therapy.

-Lamotrigine (Lamictal) 50 mg PO qd, then increase to 50-250 mg PO bid [25, 100, 150, 200 mg]; adjunct therapy .

Partial Seizure:

-Carbamazepine (Tegretol) 200-400 mg PO tid [100, 200 mg]. -Divalproex (Depakote) 250-500 mg PO tid with meals [125, 250, 500 mg].

-Valproic acid (Depakene) 250-500 mg PO tid-qid with meals [250 mg].

-Phenytoin (Dilantin) 300 mg PO qd or 200 mg PO bid [30, 50, 100].

-Phenobarbital 30-120 mg PO tid or qd [8, 16, 32, 65, 100 mg]. -Primidone (Mysoline) 250-500 mg PO tid [50, 250 mg]; metab-

olized to phenobarbital.

-Gabapentin (Neurontin), 300-400 mg PO bid-tid; max 1800 mg/day [100, 300, 400 mg]; adjunct therapy.

-Lamotrigine (Lamictal) 50 mg PO qd, then increase to 50-250 mg PO bid [25, 100, 150, 200 mg]; adjunct therapy.

-Topiramate (Topamax) 25 mg PO bid; titrate to max 200 mg PO bid [tab 25, 100, 200 mg]; adjunctive therapy.

Absence Seizure:

-Divalproex (Depakote) 250-500 mg PO tid-qid [125, 250, 500 mg].

-Clonazepam (Klonopin) 0.5-5 mg PO bid-qid [0.5, 1, 2 mg]. -Lamotrigine (Lamictal) 50 mg PO qd, then increase to 50-250

mg PO bid [25, 100, 150, 200 mg]; adjunct therapy.

10.Extras: MRI with and without gadolinium or CT with contrast; EEG (with photic stimulation, hyperventilation, sleep deprivation, awake and asleep tracings); portable CXR, ECG.

11.Labs: CBC, SMA 7, glucose, Mg, calcium, phosphate, liver panel, VDRL, anticonvulsant levels. UA, drug screen.

Endocrinologic Disorders

Diabetic Ketoacidosis

1.Admit to:

2.Diagnosis: Diabetic ketoacidosis

3.Condition:

4.Vital Signs: q1-4h, postural BP and pulse. Call physician if BP >160/90, <90/60; P >140, <50; R >30, <10; T >38.5EC; or urine output <20 mL/hr for more than 2 hours.

5.Activity: Bed rest with bedside commode.

6.Nursing: Inputs and outputs. Foley to closed drainage. Record labs on flow sheet.

7.Diet: NPO for 12 hours, then clear liquids as tolerated.

8.IV Fluids:

1-2 L NS over 1-3h ($16 gauge), infuse at 400-1000 mL/h until hemodynamically stable, then change to 0.45% saline at 125-150 cc/hr; keep urine output >30-60 mL/h.

Add KCL when serum potassium is <5.0 mEq/L. Concentration.......20-40 mEq KCL/L

Use K phosphate, 20-40 mEq/L, in place of KCL if hypophosphatemic.

Change to 5% dextrose in 0.45% saline with 20-40 mEq KCL/liter when blood glucose is 250-300 mg/dL.

9.Special Medications:

-Oxygen at 2 L/min by NC.

-Insulin regular (Humulin) 7-10 units (0.1 U/kg) IV bolus, then 7-10 U/h IV infusion (0.1 U/kg/h); 50 U in 250 mL of 0.9% saline; flush IV tubing with 20 mL of insulin solution before starting infusion. Adjust insulin infusion to decrease serum glucose by 100 mg/dL or less per hour. When bicarbonate level is >16 mEq/L and the anion gap is <16 mEq/L, decrease insulin infusion rate by half.

-When the glucose level reaches 250 mg/dL, 5% dextrose should be added to the replacement fluids with KCL 20-40 mEq/L.

-Use 10% glucose at 50-100 mL/h if anion gap persists and serum glucose has decreased to less than 100 mg/dL while on insulin infusion.

-Change to subcutaneous insulin when the anion gap has cleared; discontinue insulin infusion 1-2h after subcutaneous dose.

10.Symptomatic Medications:

-Famotidine (Pepcid) 20 mg IV q12h. -Docusate sodium (Colace) 100 mg PO qhs.