Status Epilepticus Flashcards
Status Epilepticus
Status Definition
Continuous seizure activity >5-10 min, >2 Sz w/o full recovery
Status Epilepticus
Status Causes
Withdrawal from meds, alcohol, metabolic imbalance, acute CNS insult, drug intoxication
Status Epilepticus
Status ASAP:
ASAP: ABCs (NP airway/BVM), IV, O2, monitor, VS, accu✓ (if ↓BS give 1 amp D50), protect pt (? C-spine), intubate if
hypoxia/aspiration
Status Epilepticus
Status Epilepticus
Status 1st line
1st line - Benzos(enhance GABA mediated neuronal inhibition):
lorazepam (Ativan) 0.05-0.15 mg/kg IV/IM q 5 min (slower onset than diazepam but longer acting) diazepam (Valium) 0.2mg/kg IV/IM q 5 min
midazolam (versed) 0.1mg/kg IV if no IV access/peds:
Valium 0.5mg/kg PR (max 10 mg)”
“Paraldehyde 0.3 ml/kg PR w mineral oil Versed 0.2 mg/kg IM
Will need large doses of benzos (1-2 mg/min with maximum of 10 mg), start maintenance therapy once aborted. IM versed just as good as IV ativan. If still refractory after benzo consider general anesthesia.”
Status Epilepticus
Status 2nd line
“Phenytoin (Dilantin): 20 mg/kg IV @ 50 mg/min (9mg/kg if already taking)
Na channel blockade → stabilizes membrane. On set in 20 min, duration 24 hours, don’t given in toxin induced. SE include hypotension, bradyarrhythmias, local injuries (due to propylene glycol)
Fosphenytoin 20 PE/kg IV/IM @ 150 PE/min (tips: will ppt if glucose in line; won’t work for toxic ingestion; do not use if 2nd/3rd deg block due to dysrhythmias)- cardiovascular toxicity
possibly faster, safer, given more rapidly, can be given IM Propofol- 3-5 mg/kg bolus → 1-15 mg/kg/hr infusion
Need to be ventilated, monitor for hypotension Valproic acid (Depakote)- 20-40 mg/kg IV
Unsafe in pregnancy and liver issues (increase ammonia) Keppra- 1 gm may repeat 1-2 times
Lacosamide- 200-300 mg”
Status Epilepticus
Status 3rd line drugs
3rd line - Must intubate, consult neuro & do EEG
Phenobarbital 20 mg/kg IV @50mg/min Pentobarbital 10 mg/kg IV over 1-2h, then 1mg/ kg/hr Versed 0.2 mg/kg IV, then 1-10 mcg/kg/min Propofol 1-2mg/kg IV over 1-2 min, then 10-50 mcg/kg/min
Will need to have EEG monitoring- look for burst suppression Induction:
Paralytic- Suux ok if normal prior- if concerned use roc Can use ketamine if hypotensive (3-5 mg/kg)
High dose midazolam- 10 mg loading dose, 0.1-2 mg/kg/hr maintenance (can titrate)”
Status Epilepticus
Status Kitchen Sink:
- Lidocaine 1.5 mg/kg IV Chloral hydrate 1 gm PR (peds = 50 mg/kg)
Status Hx/exam:
Onset, duration, precipitants, last sz, meds, compliance, PMHx (CVA, TIA, ICH, CA, arrhythmias), tox, pregnant, trauma;
GCS, pupils, MSE, neuro, skin
Status Epilepticus
Labs:
Levels:
CBC, BMP, Ca, Mg, LFTs, UA, hCG, UDS, coags, blood/urine cxs
EtOH, dilantin, tegretol, valproate, INH, theophylline
Status Epilepticus
Other studies outside normal labs:
Head CT, EKG
Status Epilepticus
Treatable DDx:
Eclampsia: Mg 4g IV → delivery
EtOH/malnutrition: Thiamine 100 mg IV, Mg 2g IV
INH: Pyridoxine/B6 4gm IV
Meningitis: Rocephin 2g IV and Dex 10 mg IV
OD: AC 1g/kg via OG/NG p intubation
Hyperthermia: cool
Electrolytes: correct
Trauma: neurosurgery consult
Status Epilepticus
Treatment Timeline:
Onset: glucose, electrolytes
5 min: lorazepam 4 mg IV, Midazolam 10 mg IV, antiepileptic
10 min: repeat lorazepam and midazolam
15 min: Propofol 2 mg/kg +/- ketamine 2 mg/kg, propofol infusion 50-75 mcg/kg/hr, intubate
20 min: rebolus, uptitrate, + antiepileptic
