Seizure/Status Epilepticus Flashcards
Provoked etiologies of SE
intoxication, withdrawal from EtOH or BZDs, trauma, meningitis, psychiatric, metabolic derangements
Unprovoked etiologies of SE
more difficult to determine cause, may or may not need treatment with antiepileptic medications
Physiology of seizures
brain has normal inhibitory mechanisms that prevent seizures and terminate seizures that do occur, but in a seizure, they’re out of balance
Inhibitory neurotransmitter
GABA
Excitatory neurotransmitters
glutamate, aspartate, ACh
First-line agents for seizures
BZDs to STOP the seizures
AEDs to PREVENT the seizures from occurring again
BZDs used in SE
lorazepam, diazepam, midazolam
AEDs used in SE
Phenytoin/fosphenytoin, Keppra, VPA
Lacosamide as add-on treatment
Meds used in refractory SE
Pentobarbital, phenobarbital
Med used in super-refractory SE
Ketamine
Goal of therapy in SE
achieve rapid and safe termination of the seizure, prevent seizure recurrence, avoid ADRs on the CV or respiratory systems
Burst suppression on LTM
Monitor for 24-48 hours, then IV infusions are titrated off while monitoring for seizure returns
What to do after burst suppression
Slowly wean IV infusions based on LTM reading
Usually wean agents that are causing ADRs or need for other interventions
Increase doses if seizures return
Meds to titrate off first after a burst suppression
Phenobarbital, pentobarbital, propofol, midazolam
SE treatment algorithm: stage 1- 0-10 minutes
Take care of airway, breathing, circulation, lab tests, IV thiamine followed by dextrose
Lorazepam 2-4mg IV, repeat PRN OR midazolam 10mg IM, repeat PRN
SE treatment algorithm: stage 2- 10-30 minutes
Phenytoin 20mg/kg IV OR fosphenytoin 20mg/kg PE IV
Can give additional 5-10mg/kg of either
Other options:
VPA 20-30mg/kg IV OR phenobarbital 20mg/kg IV OR Keppra 20-60mg/kg
SE treatment algorithm: stage 3- 30-90 minutes
Midazolam load 0.2mg/kg IV infusion (0.2-0.6mg/kg/hr) OR propofol load 2mg/kg IV infusion (2-5mg/kg/hr)
SE treatment algorithm: stage 4: 90 mins-hours/days
Phenobarbital load 5mg/kg IV infusion (1-5mg/kg/hr)
Refractory SE definition
Seizures lasting >2 hours OR seizures recurring at a rate of 2 or more episodes/hr without recovery to baseline between seizures, despite treatment with conventional antiepileptics
Refractory SE treatment
High-dose BZDs: midazolam bolus and infusion
2mg IV bolus + 2mg/hr, increase PRN up to 2mg/kg/hr
If this doesn’t work, you can continue to double the dose (so next time it will be 4mg IV bolus + 4mg/kg/hr, etc.)
Propofol IV infusion
Phenobarbital or pentobarbital coma
Post-intubation treatment
Paralytic is used during intubation so seizures aren’t going to be physically observed
Start IV infusion of propofol or midazolam
At this point, patients are generally on 2-3 IV anti epileptics and at least one continuous IV infusion