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Pharm Fall 2019 > Ex3 Status Epilepticus > Flashcards

Ex3 Status Epilepticus Flashcards

1
Q

status epilepticus

A

continuous seizures >/= 5minutes or consecutive, intermittent seizures w/ no signs of consciousness for >/= 5 min between each episode

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2
Q

refractory status epilepticus

A

SE that persists after standard treatment w/ at least 2 standard epileptic drugs (AED)

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3
Q

Cause of refractory SE

A

NMDA receptor upregulation (increased excitation)

GABA receptor endocytosis (increased excitation, benzo-refractory state)

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4
Q

More NMDA receptors you have

A

increased excitation

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5
Q

inability for brain to control excess cortical electrical activity

A

status epilepticus

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6
Q

Phase I (early phase)

A

initial 30 minutes of seizure activity

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7
Q

Phase II (Late Phase)

A

after 30 minutes of continuous seizure activity

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8
Q

types of SE

A

2 - convulsive SE and Non-convulsive SE

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9
Q

SE is associated with

A

Negative outcomes:

  • neuro deficit
  • mortality w/in first 3 months
  • risk of refractory SE w/ prolonged SE
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10
Q

first line pharmacologic management

A

Lorazepam*, Midazolam

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11
Q

Second line pharmacologic management

A

Valproate, (Fos)phenytoin, phenobarbital, levetiracetam

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12
Q

Third line pharmacologic management (intubated)

A

midazolam infusion
pentobarbital infusion
propofol infusion
ketamine infusion

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13
Q

Third line pharmacologic management (non-intubated)

A

lacosamide, topiramate, valproate

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14
Q

MOA for management of SE

A

Dirty mechanism

Hit all sorts of sodium, GABA, NMDA channels

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15
Q

DOC First line

A

Lorazepam

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16
Q

risk of lorazepam over time

A

propylene glycol toxicity

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17
Q

propylene glycol toxicity

A

severe hyperosmolar gap, metabolic acidosis, hypotension, multi-organ failure

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18
Q

downside of using midazolam as 1st line

A

short acting

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19
Q

Lorazepam dosages SE

A

4mg pushes (up to 8mg)

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20
Q

Which Rx can have concentrations measured?

A

Fosphenytoin, Phenytoin

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21
Q

AE Fosphenytoin

A

hypotension, arrhythmia (rate dependent) - don’t slam it in

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22
Q

Dosing of Fosphenytoin

A

18-20 mg PE/kg IV

max 150 mg PE/min

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23
Q

Dosing of Phenytoin

A

18-20 mg/kg IV

max 50 mg/min

24
Q

AE Phenytoin

A

hypotension, arrhythmia (rate dependent) - don’t slam it in

Purple glove syndrome, hepatotoxicity, propylene glycol

25
Q

AE valproic acid

A

hyperammonemia, thrombocytopenia

26
Q

RX intxn valproic acid

A

carbapenems (ANY)

27
Q

Keppra adverse effect

A

agitation

28
Q

Hepatic dysfunction - SE, which drug to use?

A
  1. Keppra (renal elimination)

2. Lacosamide

29
Q

Phenobarbiturate AE

A

propylene glycol toxicity

30
Q

lacosamide AE

A

generally well tolerated

31
Q

topiramate common side effect

A

metabolic acidosis

32
Q

pentobarbital considerations

A
  • propylene glycol
  • target is burst suppression
  • reqs mechanical ventilation
33
Q

midazolam - as 3rd line agent

A

requires mechanical ventilation

34
Q

propofol AEs

A

propofol infusion syndrome, req’s mechanical ventilation

35
Q

increased risk of propofol infusion syndrome

A

> 80 mcg/kg/min for >48h

36
Q

propofol infusion syndrome

A 
refractory bradycardia
cardiac failure
metabolic acidosis
rhabdomyolysis
hyperlipidemia
enlarged liver
renal failure
37
Q

Antidote for Isoniazide-induced seizures

A

IV pyridoxine

38
Q

Carbapenems should NOT be given with

A

valproate

39
Q

Phenobarb/pentobarbital effects on P450

A

potent inducer, other drugs will be decreased in efficacy

40
Q

Phenobarb/pentobarbital decrease levels of

A

carbamazepine, corticosteroids, lamotrigine, midazolam, fosphenytoin, valproate

41
Q

Phenytoin effects on P450

A

potent inducer, other drugs will be decreased in efficacy

42
Q

Phenytoin decreases levels of

A

carbamazepine, corticosteroids, azole antifungals, lamotrigine, midazolam

43
Q

Carbamazepine is a _______ of hepatic metabolism

A

inducer

44
Q

Carbamazepine effects midazolam by

A

CYP450 inducer - Midazolam will have reduced exposure

45
Q

Arithromycin/Erythromycin are _____ of hepatic metabolism

A

inhibitors

46
Q

Fluconazole is a ______ of hepatic metabolism

A

inhibitor

47
Q

Fluconazole will ______ levels of midazolam

A

decrease (d/t hepatic metabolism)

48
Q

Valproate is a ______ of hepatic metabolism

A

inhibitor

49
Q

Valproate will increase the exposure of

A

lamotrigene, nimodipine, phenytoin, phenobarbital, warfarin

50
Q

Common drug induced seizures

A
  1. antidepressants - bupropion (most common), TCAs
  2. pain medications (tramadol, meperidine)
  3. immunosuppressants (calcineurin inhibitors: tacrolimus, cyclosporin)
  4. others: lithium, local anesthetics, metoclopramide
51
Q

Drug induced seizures: ANTBX

A

Beta lactams - PCN, cephalosporins, carbapenems, monobactam
Isoniazid
Metronidazole

52
Q

Antipsychotics - induced seizures

A

haldol
olanzipine
quetiapine

53
Q

neuromuscular blocker resistance

A

phenytoin (induces CYP)

54
Q

topiramate - drug intxns

A

metabolic acidosis - additive

55
Q

Valproic acid + topiramate

A

hyperammonemia

56
Q

Prolongation of PR risk

A

Lacosamide + Beta Blockers, ca2+ channel blockers, fentanyl

Pharm Fall 2019 (33 decks)

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