Generalised Convulsivd Flashcards
What do they mean regarding ‘impending’ status epilepticus?
Continuous or intermittent seizures lasting longer than 5 minutes without full recovery of consciousness in between seizures
What is the incidence of CSE?
10-73 episodes per 100000 children
highest in kids under 2!150/100000
What is the mortality of CSE?
2-8%
What special population has the highest morbidity with CSE?
Neurological disorder: 10 - 20%
What are the overall objectives it CSE?
- Maintenance of ABCs
- Termination of seizures and prevention of recurrence
- Diagnosis and initial therapy for life threatening causes of CSE
- Arrange appropriate recital or ongoing care.
+/- management if refractory status epilepticus
Why do kids with CSE have airway/oxygen problems?
Clenched jaw
Poorly coordinated restorations
Secretions
Vomit
How do you manage a patient with CSEs airway
Suction. Do not prie apart jaw/teeth Oxygen 100% Head tilt chin lift \+/- assisted ventilation
Monitors
Why would patients get bradycardic or hypotensive
Hypoxia
Very ominous signs!
At what point does brain damage start to occur?
In animal models, ischaemic and excitotoxic neuronal cell loss starts after 30 minutes.
Why do we give meds at 5 minutes?
Because seizures that last longer than 5-10 minutes have high risk of continuing.
Early treatment improved outcomes.
What meds in what order?
- Benzo x 2
- Fosphenytoin, phenytoin or phenobarbital
- Fosphenytoin, phenytoin or phenobarbital
+/- paraldehyde if no IV - RSI: midazolam infusion
- Thiopental/pentobarbital
Why does treatment fail?
Inadequate dose of benzo
Treating with > 2 benzo
Delay in second line treatment
Delay in RSI
What do you do if BG
5ml/kg 10% dextrose
0.5 g/kg
When do you recheck BG post bolus in hypoglycemia?
3-5 minutes
What are some general side effects of AEDs?
Loss of airway reflexes
Hypotension
Respiratory depression
Cardiac arrhythmia
How effective are benzos at stopping seizures?
70-85%
Especially if given within 20 minutes
Buccal: 75%
PR: 59%
Intranasal: 88%
IV: 92%
Are the repeat doses of benzo as effective as the first?
No.
1st 85%
Repeat 17%
What is the preferred second line medication?
Fosphenytion/phenytoin.
Why: less respiratory depression and altered level of consciousness than phenobarbital
What are your options for second line meds if there is no IV?
IM fosphenytoin
IO phenytoin
PR paraldehyde
NB the evidence for safety and efficacy of IO phenytoin or phenobarbital is scant
What is the dose of phenytoin?
Any special administration
20 mg/kg
Put it in NS
Over 20 minutes
It has a high PH and if it extravasates and causes severe irritation: purple glove syndrome!
What is special about fosphenytoin and what’s the dose?
Pro drug
To avoid purple glove syndrome.
20mg/kg
Side effects of phenytoin and fosphenytoin ?
Cardiac Arrhythmias, bradycardia, hypotension
What’s the dose of phenobarbital?
Anything special?
20 mg/kg
Good for babies.
SE respiratory depression, sedation and hypotension
Similar MOA as benzos - so refractory seizures don’t respond.
Why is paraldehyde only given rectally?
Because of side effects of IM and IV: cyanosis, cough, hypotension and pulmonary oedema.
What is the dose of paraldehyde?
0.4 ml/kg PR
Any special meds for CSE?
Sodium valproate 30 mg/kg
Less SE especially resp or CVS
Pyridoxine for kids
Does a normal CT rule out increased ICP?
No
Who do you refer to a neurologist?
CSE: and no prior history of epilepsy, even febrile
How do you manage refractory CSE?
Midazolam infusion: loading 0.15 mg/kg then infusion to a maximum of 24 ug/kg/min
SE hypotension.
Barbiturates (thiopental or pentobarbital):
T 2 mg/kg then 2 mg/kg/h
Once controlled x 48 hours decrease 25% q3h
P 10 mg/kg then 1mg/kg/h
Propofol, topiramate, levetiracetam
What is the definition of CSE?
- continuous generalised tonic-clinic seizure activity with LOC for longer than 30 minutes
- two or more discrete seizures without a return to baseline mental status
