Status Epilepticus- MJ Flashcards
(39 cards)
In general, what is the order of treatment for a person with Status Epilepticus?
(I got this from a youtube video but it aligns with her info)
- 1st line= Benzos every 5min
* Lorazepam IV (1st line) or Midazolam (IM/IN) or PR diazepam - If still seizing: Phenytoin or IV Phenobarbital/valproic acid
- Last resort: General anesthesia, intubation and EEG monitoring
Generalized convulsive status epilepticus (GCSE) is:
- Any recurrent or continuous seizure activity lasting longer than ____ minutes and patient does not regain baseline mental status
- Any seizure that does not stop within ____ minutes should be aggressively treated as impending SE.
- 30 minutes
- 5 minutes
T/F: Generalized convulsive status epilepticus (GCSE) is a life threatening medical emergency?
TRUE!
•Any seizure that does not stop within 5 minutes should be aggressively treated as impending SE.
Pathophysiology of GCSE:
Seizure initiation caused by an imbalance between ______ and _____ neurotransmission
Excitatory (Glutamate, Ca, Na, etc)
and
inhibitory (GABA, adenosine, K, opioide peptides, Galantin, etc) neurotransmission
The pathophysiology of GCSE is seizure initiation caused by an imbalance b/w excitatory (Glutamate) and inhibitory neurotransmission (GABA).
Sustained depolarization can result in what?
Neuronal death
The following pathophysiology is asosciated with early or late seizure?
- Marked increases in plasma epinephrine, norepinephrine, steroid concentrations
- HTN, tachycardia, cardiac arrhythmias
- Muscle contractions and hypoxia
- Acidosis
- Hypotension, shock
- Rhabdomyolysis, and secondary hyperkalemia
- Acute tubular necrosis may ensue
Early (0-30 minutes)
The following pathophysiology is asosciated with early or late seizure?
–Decompensation of patient
–Hypotensive with compromised cerebral blood flow
–Serum glucose may be normal or decreased
–Hyperthermia, respiratory deterioration, hypoxia, and ventilatory failure may develop
Later (30+ minutes)
T/F: In prolonged seizures, motor activity may cease, but electrical seizures may persist
True
What are the 5 goals of treatment of Generalized convulsive status epilepticus (GCSE)
- Identify GCSE subtype and precipitating factors
- Terminate clinical and electrical seizure activity ASAP, and preserve cardiorespiratory function
- Minimize side effects
- Prevent recurrent seizures
- Avoid pharmacoresistant epilepsy and/or neurologic sequelae
What is the treatment of Impending GCSE (0-30 minutes)?
-
Lorazepam* (preferred benzo)
- efficacy and long duration of action in the CNS
- Midazolam (preferred for IM, intranasal (IN) and buccal admin)
- Diazepam (rectal- caregiver option)
“Love Mi Dog”
What are the established first line GCSE treatments (30-60 min)?
•Hydantoins
- phenytoin and fosphenytoin
- long-acting anticonvulsants
- given concurrently with benzodiazepines
What is the treatment for refractory GCSE (>120min)?
•Treatment then First line: (want to anesthetize)
- Anesthetic doses of midazolam
- Pentobarbital
- Propofol
What are 2nd and 3rd line established GCSE treatments (30-60 minutes)?
Second line:
- Phenobarbitol
- valproate
Third line:
- Lacosamide
- Levatiracetam
What makes GCSE considered to be refractory?
•GCSE is considered to be refractory when seizure is not controlled by two anticonvulsants
What are the 5 final tx options for super-refractory GCSE?
- Ketamine
- Hypothermia
- Lidocaine (prob wouldn’t give)
- Topiramate (give nasogastrically- crush tabs into water)
- Inhaled anesthetics (not used until other approaches fail)
What is the Mechanism of Ketamine in the tx of super-refractory GCSE?
- may increase the # of NMDA receptor to increase glutamate’s effect
- may also possess an antagonistic effect on NMDA receptors
The following is the mechanism of what final tx option for super-refractory GCSE?
- reduces excitatory transmission and epileptic discharges and reduces brain edema, cerebral metabolic rate, oxygen utilization, and ATP consumption
- core body temp of ~32°C -35°C is targeted for at least 24 to 48 hours
- significantly reduce the clearance of several drugs, including anesthetics and antiepileptics
- Hypothermia
The following are final options for what type of GCSE?
- Immunomodulating therapy
- corticosteroids and IV immune globulin
- Ketogenic diet
- Vagal nerve stimulation (grade D)
Super-refractory GCSE final options
What has animal data suggested regarding the use of Immunomodulating therapy of super-refractory GCSE
suggest the development of super-refractory GCSE may be due to antibodies directed against the voltage-gated potassium channels and the NMDA receptor
What are the 2 ADEs of Diazepam and how do you monitor?
ADEs: Hypotension and cardiac arrhythmias
Monitor: Vital signs and ECG during administration
Which medication?
- Propylene glycol causes hypotension and cardiac arrhythmias when administered too rapidly
- hypotension may occur with large doses
Diazepam
(Propylene glycol stabilizes drug but too much can cause lactic acidosis)
What are the 4 ADEs of Fosphenytoin and how do you monitor?
- Hypotension
- Cardiac arrhythmias
- Paresthesia
- Pruritus
Monitor vital signs and ECG during administration
Which med?
- Hypotension is less than that noted with phenytoin, as this product does not contain propylene glycol
- Pruritus generally involves the face and groin areas, is dose and rate related, and subsides 5-10 minutes after infusion
Fosphenytoin
