Ex3 Status Epilepticus Flashcards
status epilepticus
continuous seizures >/= 5minutes or consecutive, intermittent seizures w/ no signs of consciousness for >/= 5 min between each episode
refractory status epilepticus
SE that persists after standard treatment w/ at least 2 standard epileptic drugs (AED)
Cause of refractory SE
NMDA receptor upregulation (increased excitation)
GABA receptor endocytosis (increased excitation, benzo-refractory state)
More NMDA receptors you have
increased excitation
inability for brain to control excess cortical electrical activity
status epilepticus
Phase I (early phase)
initial 30 minutes of seizure activity
Phase II (Late Phase)
after 30 minutes of continuous seizure activity
types of SE
2 - convulsive SE and Non-convulsive SE
SE is associated with
Negative outcomes:
- neuro deficit
- mortality w/in first 3 months
- risk of refractory SE w/ prolonged SE
first line pharmacologic management
Lorazepam*, Midazolam
Second line pharmacologic management
Valproate, (Fos)phenytoin, phenobarbital, levetiracetam
Third line pharmacologic management (intubated)
midazolam infusion
pentobarbital infusion
propofol infusion
ketamine infusion
Third line pharmacologic management (non-intubated)
lacosamide, topiramate, valproate
MOA for management of SE
Dirty mechanism
Hit all sorts of sodium, GABA, NMDA channels
DOC First line
Lorazepam
risk of lorazepam over time
propylene glycol toxicity
propylene glycol toxicity
severe hyperosmolar gap, metabolic acidosis, hypotension, multi-organ failure
downside of using midazolam as 1st line
short acting
Lorazepam dosages SE
4mg pushes (up to 8mg)
Which Rx can have concentrations measured?
Fosphenytoin, Phenytoin
AE Fosphenytoin
hypotension, arrhythmia (rate dependent) - don’t slam it in
Dosing of Fosphenytoin
18-20 mg PE/kg IV
max 150 mg PE/min
Dosing of Phenytoin
18-20 mg/kg IV
max 50 mg/min
AE Phenytoin
hypotension, arrhythmia (rate dependent) - don’t slam it in
Purple glove syndrome, hepatotoxicity, propylene glycol
AE valproic acid
hyperammonemia, thrombocytopenia
RX intxn valproic acid
carbapenems (ANY)
Keppra adverse effect
agitation
Hepatic dysfunction - SE, which drug to use?
- Keppra (renal elimination)
2. Lacosamide
Phenobarbiturate AE
propylene glycol toxicity
lacosamide AE
generally well tolerated
topiramate common side effect
metabolic acidosis
pentobarbital considerations
- propylene glycol
- target is burst suppression
- reqs mechanical ventilation
midazolam - as 3rd line agent
requires mechanical ventilation
propofol AEs
propofol infusion syndrome, req’s mechanical ventilation
increased risk of propofol infusion syndrome
> 80 mcg/kg/min for >48h
propofol infusion syndrome
refractory bradycardia cardiac failure metabolic acidosis rhabdomyolysis hyperlipidemia enlarged liver renal failure
Antidote for Isoniazide-induced seizures
IV pyridoxine
Carbapenems should NOT be given with
valproate
Phenobarb/pentobarbital effects on P450
potent inducer, other drugs will be decreased in efficacy
Phenobarb/pentobarbital decrease levels of
carbamazepine, corticosteroids, lamotrigine, midazolam, fosphenytoin, valproate
Phenytoin effects on P450
potent inducer, other drugs will be decreased in efficacy
Phenytoin decreases levels of
carbamazepine, corticosteroids, azole antifungals, lamotrigine, midazolam
Carbamazepine is a _______ of hepatic metabolism
inducer
Carbamazepine effects midazolam by
CYP450 inducer - Midazolam will have reduced exposure
Arithromycin/Erythromycin are _____ of hepatic metabolism
inhibitors
Fluconazole is a ______ of hepatic metabolism
inhibitor
Fluconazole will ______ levels of midazolam
decrease (d/t hepatic metabolism)
Valproate is a ______ of hepatic metabolism
inhibitor
Valproate will increase the exposure of
lamotrigene, nimodipine, phenytoin, phenobarbital, warfarin
Common drug induced seizures
- antidepressants - bupropion (most common), TCAs
- pain medications (tramadol, meperidine)
- immunosuppressants (calcineurin inhibitors: tacrolimus, cyclosporin)
- others: lithium, local anesthetics, metoclopramide
Drug induced seizures: ANTBX
Beta lactams - PCN, cephalosporins, carbapenems, monobactam
Isoniazid
Metronidazole
Antipsychotics - induced seizures
haldol
olanzipine
quetiapine
neuromuscular blocker resistance
phenytoin (induces CYP)
topiramate - drug intxns
metabolic acidosis - additive
Valproic acid + topiramate
hyperammonemia
Prolongation of PR risk
Lacosamide + Beta Blockers, ca2+ channel blockers, fentanyl
