ILAE define 20 years ago as a single seizure of >30 minute duration or a series of epileptic seizures during which function is not regained between ictal event in a 30 minute period.
Definition
Status should be interrupted urgently due to decrease mortality ,cardiorespiratory morbidity or refractory status.
>5 minutes of continious seizures or 2 or more seizures between which there is
incomplete recovery of consciousness
Operational definition
Ongoing convulsive or nonconvulsive seizures following administration of an initial benzodiazepine and a nonbenzodiazepine AED , given in appropriate dose.
Incidence : 30%
Refractoty status epilepticus
Generalized Convulsive Status Epilepticus (GCSE)
Focal motor status epilepticus Myoclonic status epilepticus Tonic status epilepticus Non Convulsive Status Epilepticus (NCSE)
Classification
Incidence : 7-41 per 100,000
Bimodal age distribution : peak incidence rate in <1 and above 60 years .
Epidemiology
Acute symptomtic Remote symptomaticAED nonadherenceWithdrawal syndromeMetabolic abnormality or sepsisUse of drugs that lower seizure tresholdAutoimmune or paraneoplastic encephalitisNew onset refractory status
Etiology
Acute symptomtic Remote symptomaticAED nonadherenceWithdrawal syndromeMetabolic abnormality or sepsisUse of drugs that lower seizure tresholdAutoimmune or paraneoplastic encephalitisNew onset refractory status
Etiology
Acute symptomtic Remote symptomatic AED nonadherence Withdrawal syndrome Metabolic abnormality or sepsis
Etiology
Acute symptomtic Remote symptomatic AED nonadherence Withdrawal syndrome Metabolic abnormality or sepsis Use of drugs that lower seizure treshold
Etiology
Theophylline Imipenem High dose of penicillin G Quinolone Metronidazole INH Tricyclic antidepressant Bupropion Lithium Clozapine Flumazenil Cyclosporine Lidocaine
Acute symptomtic Remote symptomatic AED nonadherence Withdrawal syndrome Metabolic abnormality or sepsis Use of drugs that lower seizure treshold Autoimmune or paraneoplastic encephalitis
Etiology
Acute symptomtic Remote symptomatic AED nonadherence Withdrawal syndrome Metabolic abnormality or sepsis Use of drugs that lower seizure treshold Autoimmune or paraneoplastic encephalitis New onset refractory status
Etiology
Initial assessment and suport Initial pharmacologic therapy Alternative second line therapies Out of hospital/prehospital treatment
Treatment
Assessment of cardiorespiratory function Oral airway Intravenous line Blood is drawn for glucose, BUN,
electrolytes, and a metabolic and drug screen.
Normal saline infusion Glucose (with thiamine if malnutrition and
alcoholism are potential factors).
Initial assessment and suport
Lorazepam 0.1 mg/kg , upto 4mg per dose Diazepam 0.15 mg/kg ,up to 10 mg per
dose Midazolam 5-10 mg IM Clobazam
Benzodiazepines
First-line (Grade 1A) Time of from its injection to its maximum
effect : 2 min Effective duration of action against seizure :
4-6 hours Rate of injection : 2 mg/min This should be repeated after 1 min if
seizure continue.
Lorazepam
High lipid solubility Rapidly cross BBB Rapid onset of its effect : 10-20 seconds Initial termination of seizure : 50-80 % Durartion of anticonvulsants effect : <20
min Recurence of seizure : 50% in 2 hr Rate of injection : 5 mg/min
Diazepam
Rectal gel of diazepam is also available Provide rapidly delivery , when IV access is
dificult , or for at home use for patients who have frequent repetitive or prolonged seizures
Diazepam
Rapid onset in termination of seizure activity : less than 1 minute
Short half life in CNS Administration route: IM , buccal , intranasal Very effective when IV access is not
available : pre-hospital treatment
Midazolam
Onset of effect between diazepam and lorazepam
Duration of effect is more prolonged than diazepam
IV injection Can be used in refractory status as adjuant
therapy when given entrally by NG tube.
Clobazam
First line (Grade 2C) Preferred formulation of phenytoin Water-soluble Loading dose: 20-30 mg/kg Lower risk of irritation at injection site Rate of infusion :100-150 mg/min However, the delay in hepatic conversion of
fosphenytoin to active phenytoin makes the latency of clinical effect approximately the same as phenytoin
Fosphenytoin
Can be given intramuscularly in cases where venous access is difficult ,however less predictable effect and longer time to onset of seizure activity
Less cardiovascular effect compare to phenytoin
Fosphenytoin
loading dose : 20 mg/kg Intravenous Rate of injection: less than 50 mg/min If seizures continue, an additional 5 mg/kg is
indicated More rapid administration risks hypotension
and heart block Must be given through a freely running line
with normal saline (it precipitates in other fluids)
Should not be injected intramuscularly.
Phenytoin
Phenytoin (but not phosphenytoin) and any of the benzodiazepines are incompatible and will precipitate if infused through the same intravenous line
Phenytoin
In an epileptic patient known to be taking anticonvulsants chronically but in whom the serum level of drug is unknown, it is probably best to administer the
full-recommended dose of phenytoin
Phenytoin
Preferred to phenytoin in primary CGSELoading dose: 20mg/kgFDA approved only for slow infusion
rate :20mg/ minRate of seizure control ; 50-90%
Valproate
Loading dose:20mg/kg Infusion rate: 30-50mg/min Intuabation is often required to provide
secure airway Side efects :sedation , respiration arrest Half life : 87-100 hr
Phenobarbital
Ongoing convulsive or nonconvulsive seizures following administration of an initial benzodiazepine and a nonbenzodiazepine AED , given in appropriate dose
Refractoty status epilepticus
The optimal treatment of RSE is more contoversial.
It is critical to provide adequate ventilatory and hemodynamic support
Patients should be intubated and monitored by continious electroencephalogram.
Refractoty status epilepticus
Main points in selection of drugs: -Urgency of seizure control -Pharmakokinetic of various drugs -Drugs already used and failed -Potential complication of treatment (hypotension & risk of prolonged MV)
Refractoty status epilepticus
Pentobarbital is more popular ,because more seizure control rate , but has more sedation and more ventilatory need
Pentobarbital and propofol have greater risk of hemodynamic instability.
Refractoty status epilepticus
Midazolam & propofol have advantages for patients at risk for ventilatory dependence with prolonged therapy(severe pulmonary disease ,severe debilitation, or malignancy)
Refractoty status epilepticus
Water soluble, rapidly acting banzodiazepine
loading dose : 0.2 mg/kg Infusion rate : 2mg/min Additional dose should be given every 5
min,until seizure stop (max dose : 2 mg/kg) Followed by an continious infusion of 0.1 to
0.4 mg/kg/h(can be titrated upwardly upto 5mg/kg/hour) with control of blood pressure
Midazolam
If seizure continue within 45-60 minute, propofol or pentobarbital should be started
Side effects: hypotension(less common than pentobarbital) ,tachyphylaxis ,withdrawal seizure ,
Relapse of seizure is more common when higher doses is used.
Midazolam
Highly lipophilic phenol , GABA-A agonist
loading dose : 1-2 mg/kg( in 5 min) and then repeated until seizure stop
Continious infusion as an intravenous drip of 2 to 8 mg/kg/h may be required but should not be maintained more than 48 hr.
Propofol
Propofol infusion syndrome : rhabdomyolysis, severe matabolic
acidosis ,and cardiac and renal failure
More common in prolonged use (48 hr) and in infusion rates of greater than 5mg/kg/hr.
ABG, CPK, lactic acid, TG, amylase should be checked.
Propofol
If seizure controlled with propofol , the effective infusion rate should be maintained for 24 hr , and then tapered 5% per hr.
Propofol
Loading dose:5mg/kg over 10 min. Max infusion rate :50mg/min If seizure persist: additional 5mg/ kg dose Continious infusion rate: 1 mg/ kg/hr Side effects: hypotension, prolonged
sedation If seizure controlled , infusion must be
continued for 24 hr before discontinuation of drug.
Pentobarbital
Petit mal status should be managed by intravenous lorazepam, valproic acid, or both, followed by ethosuximide.
Nonconvulsive status is treated along the
lines of grand mal status, usually stopping short of using anesthetic agents.
Myoclonic status is treated with benzodiazepines and valproate .
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