286 Emergency Medicine
Phenytoin(a)is a second-line agent that can be administered intra-
venously. Although the cause of the patient’s seizure may be because of sub-
therapeutic levels of phenytoin, benzodiazepines are still the first-line
therapy owing to their rapid onset. The onset of diazepam is 2 to 5 minutes
while phenytoin is 10 to 30 minutes. In addition, phenytoin requires at
least 20 minutes for administration because of its potential to cause
hypotension and cardiac dysrhythmias. Phenobarbital (c)is a third-line
agent. Its onset of action is 15 to 30 minutes. Valproic acid (d)is rarely
used in the acute seizure setting. There is no role for lithium (e)in acute
seizure management.
259.The answer is a. (Rosen, pp 2421-2424.) This patient has
postpartum eclampsia, which needs to be managed with magnesium
sulfateand admission to the obstetrical service. Preeclampsia is defined as
new-onset hypertension (> 140/90 mm Hg) and proteinuria (1 g/L in ran-
dom specimen or > 3 g/L over 24 hours). Some clinicians also use general-
ized edema as a requirement. Preeclampsia is most common in the third
trimester. Eclampsia occurs with the development of seizures or coma in a
patient with preeclampsia. A preeclamptic woman may worsen after deliv-
ery and develop late postpartum eclampsia, which usually occurs in the first
24 to 48 hours postpartum but may present several weeks after delivery.
Management of eclamptic seizures in the ED involves administering magne-
sium sulfate, which is believed to act as a membrane stabilizer and vasodila-
tor, reducing cerebral ischemia. Although magnesium sulfate is not a direct
antihypertensive, the hypertension associated with eclampsia is often con-
trolled adequately by treating the seizure.
(b)Treating the seizure will most likely also lower the patient’s BP. Less
than 10% of eclamptic patients require specific antihypertensive therapy.
(c)This is the treatment for migraines, which this patient does not have.
(d and e)This patient’s seizure is secondary to eclampsia. The first-line
treatment is with magnesium sulfate. If the seizure is not treated despite
appropriate magnesium sulfate then a benzodiazepine can be administered
and etiologies of seizure other than eclampsia should be sought.
260.The answer is b.(Rosen, p 290.)The patient has a triad of hypertension,
bradycardia, and respiratory depression, which is called Cushing reflex.
This is observed in one-third of patients with a potentially lethal increase in
ICP. Increased ICP may result from traumatic brain injury or, as in this patient’s
case, from hemorrhagic stroke and subsequent brainedema. Tobacco andcocaine