Status Epilepticus - mc.vanderbilt.edu ppt...•CBC, BMP, EKG, UDS, TFT, LFTs, Ammonia all...
Transcript of Status Epilepticus - mc.vanderbilt.edu ppt...•CBC, BMP, EKG, UDS, TFT, LFTs, Ammonia all...
Objectives
• Define Status Epilepticus
• Describe the pathophysiology of SE
• Discuss the etiology of SE
• Discuss the treatment of SE
• Identify complications and outcomes associated with SE
Case Study
• M.K. -19 yo female with memory difficulties x 3 months
• Acute onset of visual and auditory hallucinations ending in confrontation with campus police
• Taken to local hospital
– No recollection of outburst
– CTH unremarkable
– Brain MRI ordered
Case Study
• While on MRI table M.K. has a generalized seizure lasting approximately 30 seconds
• Post seizure M.K. is noted to be unresponsive
– STAT team is called
• Upon arrival of the STAT team M.K. has a second generalized seizure
– requires intubation for airway protection
Criteria for SE
• Old (30 minute rule) vs New (NOW!)
• TIME is BRAIN
• ≥5 minutes of continuous seizures OR ≥2 discrete seizures between which there is incomplete recovery of consciousness
Neurocritical Care, 2012
Status Epilepticus
• Categorized electroclinically (focal or generalized)
– Morbidity
– Identify etiology
• Classified as Convulsive and Nonconvulsive
SE Chart
Convulsive
• Convulsions associated with rhythmic jerking of the extremities
• Types
– Generalized (most common)
• Myoclonic
• Clonic
• Tonic
• Tonic –Clonic
– Partial
• Simple
• Complex
Nonconvulsive
• Sz activity seen on EEG without clinical findings
• Types
– Partial (simple and complex)
– Absence
– Others (rare)
• Diagnosed based on
– Etiology
– EEG findings
• Captures 56% of seizures in first hour
• 88% of seizures in first 24h
– Clinical status of patientUpToDate, 2015Sutter et al, 2013
Neurocritical Care, 2012
Status Fast Facts
• First described on tablets from 718-612 BC
• Incidence: 7-41 cases per 100,000 adults per year
• $4 billion per year in healthcare costs (U.S.)
• Incidence rates peak in children < 1 year of age and adults > 60 years
• 10% of adults with epilepsy will have status epilepticus
• Mortality rate can be around 20%, especially if treatment is not initiated quickly
– Highest mortality occurs with anoxic and cerebrovascular causes
– Seizure duration is greatest predictor of mortality. SE lasting > 1 hour has significantly higher mortality
Lancet Neurol, 2006
More Facts
• In Neuro Intensive Care Units, up to 1/3 of patients will have nonconvulsive seizures and most of these will be in nonconvulsive status epilepticus (Jordon KG 1994)
• In Medical Intensive Care Units, up to 10% of patients undergoing continuous EEG monitoring have nonconvulsive seizures (Towne
AR et al 2000)
Case Study
• M.K. arrives to the ICU intubated but starts to have a third seizure shortly after arrival
• cEEG immediately obtained and reveals an abnormal generalized rhythmic delta activity consistent with SE
Question #2
What medication class is considered first line for the treatment of seizures?
A. Neuromuscular blocking agents
B. Benzodiazepines
C. General anesthetics
D. AEDs that affect voltage- dependent sodium channels
E. None of the above
Give a Benzo!
• No Access = No Excuse
– IV: lorazepam, midazolam, diazepam
– IM: midazolam
– Intranasal: midazolam
– PR: diazepam
• Diazepam crosses BBB, short acting, stable at room temperature
• Midazolam extremely short acting, multiple route administration
• Lorazepam ? Best benzo, long acting
Randomized, Double-blind study that compared IV lorazepam, IV diazepam, and placebo
205 patients total • 66 patients in lorazepam arm (59% seizure cessation)• 68 patients in diazepam arm (43% seizure cessation)• 71 Patients in placebo arm ( 21% seizure cessation)
5 year Multi-center, Double-blind study that compared IV diazepam + IV phenytoin, IV lorazepam, IV phenobarbital, and IV phenytoin
Included both convulsive (384 patients) and non-convulsive SE (134 patients)
lorazepam 65%phenobarbital 58%diazepam + phenytoin 56%phenytoin 44%
Large (N= 893), Double-blind, Randomized trial comparing IM midazolam to IV lorazepam
73% (IM midazolam) vs 63% (IV lorazepam) seizure cessation
Next Steps
• ? Time dependent loss of synaptic GABA receptors
• Window of effective anticonvulsant therapy is NARROW
• Treatment algorithms
– Prevents neuronal injury
– Maximizes cerebral O2 supply
– Decrease morbidity/mortality
Neurol Lancet, 2006
Complications
• Cardiac arrhythmias
• Hypotension
• Hypoventilation/Hypoxia
• Aspiration pneumonitis
• Neurogenic pulmonary edema
• Metabolic lactic acidosis
• Hyperthermia
• Cardiac injury 2/2 catecholamine releaseUpToDate, 2015
Case Study
• 2 mg IV lorazepam administered STAT and Fosphenytoin load is ordered with improvement in EEG
• STAT Neurology consult placed
• MRI without abnormalities
• Family arrives to bedside
Case Study
• No prior seizure history
• Memory issues and personality changes x3 months
• No home meds or prior medical history
• Parents deny recent fever, chills, malaise
Pathophysiology
• A seizure can be caused by any process that disrupts the cell membrane stability of a neuron
• The point at which the cell membrane becomes destabilized and an uncontrolled electrical discharge begins is known as the seizure threshold
• Lower the seizure threshold = more prone to seizures
UptoDate, 2015
Etiology
50% of seizures/SE are acute symptomatic
– Stroke
– Trauma
– Cerebral hypoxia
– Infection
– Tumor
Etiology
• AED noncompliance or use of drugs that lower seizure threshold
• Substance withdrawal
• Metabolic derangements
• Infectious cause
• Autoimmune/Paraneoplastic
Question # 4
What diagnostics and labs should be obtained?
A. CBC
B. BMP
C. UDS
D. CXR
E. LP
F. Pan cultures
G. Others?
• CBC, BMP, EKG, UDS, TFT, LFTs, Ammonia all unremarkable
• CXR shows widened mediastinum
• Blood, urine, sputum cultures (-)
• LP performed
– Nucs 0
– Glu 58 mg/dl
– Protein 40 mg/dl
– PCR negative for HSV
Etiology?
• Brain Injury/Insult
• AED noncompliance or use of drugs that lower seizure threshold
• Metabolic
• Infectious
• Autoimmune/Paraneoplastic Encephalitis
Autoimmune and Paraneoplastic Encephalitis
• Neoplastic Lung CA
• Anti-body Specific Syndromes
– Antibodies to intracellular antigens
• Ma2-associated encephalitis Testicular tumors
• Anti-CRMP5 encephalomyelitis NSCLC & Thymomas
– Antibodies to synaptic proteins
• Anti-NMDA receptor encephalitis
• Several others
Anti- NMDA Encephalitis
• Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis
– Psychiatric symptoms
– Seizures
– Memory deficits
– Dyskinesias
• IgG antibodies to NMDAR found in serum or CSF
• Think teratoma !!
• Treatment resection of tumor, IV IG, glucocorticoids
Case Study
• CSF (+) for Anti-NMDA
• CT of C/A/P shows mediastinal mass
• Resection with pathology confirmation
• Discharged from hospital to rehab after ~ 3 weeks
• 6 months follow up M.K. was back to attending classes
• Deficitmild short term memory deficits
Outcomes
• 20% mortality with first episode of GCSE
• 69-81% mortality for SE + anoxia
• Etiology = most important predictor of outcome
• Approximately 10-50% of survivors have residual neurological deficits
• Significant risk for recurrent seizures or SE
Neurology, 2007UpToDate, 2015
Summary
• Status Epilepticus is life threatening and seizures should be stopped as quickly as possible
• Remember sometimes status seizures are not obvious, symptoms can be very subtle or may only present as altered mental status
• Give a Benzo!
• Remember your ABCs
• Consult Neurology STAT
• Identify the cause as quickly as possible to improve outcomes
References
Alderedge, B., Gelb, A. et al. A comparison of lorazepam, diazepam and placebo for the treatment of out of hospital status epilepticus. N Engl J Med 2001; 345:631
Brophy, G., Bell, R., Claassen, J., et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17:3
Chen, J., Wasterlain, C. Status epilepticus: Pathophysiology and management in adults. Neurol Lancet 2006; 5:3
Dalmau, J., Rosenfield, M. Paraneoplastic and autoimmune encephalitis. August 2015. http://www.uptodate.com
Drislane, F., Convulsive status epilepticus in adults: Treatment and prognosis. April 2015. http://www.uptodate.com
Gaspard, N., Jirsch, J., Hirsch, L. Nonconvulsive status epilepticus. April 2015. http://www.uptodate.com
Hauser, W. Status epilepticus: Epidemiologic considerations. Neurology 1990; 40:9.
Hesdorffer, D., Logroscino, G., Cascino, G., Hauser, W. Recurrence of afebrile status epilepticus in a population-based study in Rochester, Minnesota. Neurology 2007; 69(1):73
Lowenstein, D., Bleck, T., Macdonald, R. It’s time to revise the definition of status epilepticus. Epilepsia 1999; 40:120
Silbergleit, R., Durkalski, V., et al. Intramuscular versus intravenous therapy for prehospital status epilepticus N Engl J Med 2012; 366:591
Sutter, R., Stevens R., Kaplan P. Continuous Electroencephalographic monitoring in critically ill patients: Indications, limitations, and strategies. CCM Journal. 2013, 41(4) 1124-1132
Treiman, D., et al. A comparison of four treatments for generalized convulsive status epilepticus. N Engl J Med 1998; 339:792.