status epilepticus Flashcards
Emergent Status Epilepticus Management
first: assess blood glucose
if BG is < 70…
1. give thamine (to prevent wernicke’s encephalopahty)
2. give dextrose (for the low glucose)
if the seizure is done = you’re done here
if the pt. BG NOT < 70 or they continue seizing…
Benzodiazepines are first line emergent therapy for status
- give lorazepam IV push & repeat every 5-10 minutes until seziure ends
Supportive Care for Status Epi.
what should you be doing in addition to seizure treatment
- ABCs
- FS BG
- IV access
- neruo exam
- labs
- urinary cath
- continuous EEG
- get the diagnosis; underlying reason
Emergent Status Treatment: Benzo Use
- specifics
- which benzo
- back up
Benzo: first line emergent status epi. medication
Monitor
- RR (can decrease respiratory drive)
- blood pressure (hypotension)
- watch for seizure termination & return to baseline!
lorazapamIV push: eveyr 5-10 minutes
- may need to intubate or give pressors to keep BP and RR ok
Alternative Benzo: Diazepam IV
- doesnt hit BBB as fast becuase lipophilic
- canbe give PR if not in hospital
Alternative: Midazolam (IM, IN, buccal)
Urgent Status Epi. Treatment
- after benzo administeration
- treatment goals for this step
Urgent: after benzo
- you NEED to give an AED in all pts. after you give benzo (except if it was a BG too low seizure)
the GOAL of the anti-epileptic drug (AED) depends on if the seizure is still occuring or if it has stopped
if seizure was aborted with benzo
- goal is to rapidly get pt. to therapeudic levels of the AED and continue with maitnence treatment
if seizure was NOT ABORTED with benzo
- goal is to terminate with a different medication
- you will go to this usually after 2-3 adminsterations of the lorazapam 5-10 mins apart
Urgent Treatment: Status Epi
what AED’s are used
Anti-epileptic Drugs
- fosphenytoin preferred or phenytoin IV
- valproate
- phenobarbital
- the pt. home AED: if they’re not at therapeudic dose and avalible IV
if pts. seizure was ABORTED with benzo = choose phenyotin
- get them to therapeudic levels ASAP and maintence
- penytonin has slower admin rates: but because the seizure is aborted this is ok
if pts. seizure was NOT aborted with benzos = use fosphenytoin
- terminates seizure FASTER: since you can give 3x the dose as phenytoin
Urgent: status epi. treatment
Phenytoin dosage
ADR
monitoring
Phenytoin: given for those who’s seizures were aborted with a benzo
giving phenytoin IV at 50mg/min
ADR
- hypotension = monitor BP
- arrythmias = EKG monitor
- extravasation: leading to tissue discoloration, edema, pain or skin necrosis purple glove syndrome (leakage out of vessels into tissues) = monitor site of infusion
Monitoring
- check level 1 hours after the IV loading dose is done
Urgent: status epi. treatment
Fosphenytoin dosage
ADR
monitoring
Fosphenyotoin: given for those who’s seizures were NOT aborted with benzos during the emergent phase
given at a 3x faster rate: given IV 150 mg/min
dosed in phenytoin equlivelants or PE’s
so 150 mg phenytoin = 15o fosphenytoin mg PE
ADR
- hypotension = monitor BP (less than phenytoin)
- arrythmias = monitor EKG (less than phenytoin)
- parasthesias and puritis of face and groin
MOnitoring
- check phenytoin leverl after 2 hours of IV loading dose: side fosphenyotin is a prodrug: coverted into
Urgent Status epi:
use of phenobarbitol?
use of valproate sodium?
Phenobarbital: not likely to work in somone who has failed benzos or fos/phenytoin but an option for urgent treatment
ADR
- sedation
- hypotension
- respiratory depression = mechanical vent.
Valproate Sodium
- similar effect to phenytoin: but we still prefer phenytoin
- fewer cardivoascular effects
Refractory Status Epilepticus
definition
Definition of Refractory Status
- failure of benzo + AED to abort the seizure
- seizure lasting longer than 30-60 minutes
These pts. are unlikely to return to their baseline sate of functioning
at this point, the clinical signs of the sizure may become subtle: no longer outward but more seizure activity seen on EEG: non-convulsive
Treatment of Refractory Status epilepticus
search for the cause & treat that if you can
- CNS infection
- CNS tumor
- drug/toxin
- metabolic disorder
- liver failure
- fever
Treatment
- continue prior AED you started during urgent stage
- intubate and mechanically vent.
- try to suppression seizure activity on EEG
Medications to Use
- ideally: youll titrate them up on these meds until dramatic suppression of EEG seizure activity is noted; keep this way for 24 hours, then ween off & a secondary AED med
Midazolan continuous IV: no max dose
propofol continuous IV
phentobarbitol
levetiracetam
ketamine
Treatment of refractory status epi: Propofol specifics
Propofol
Indicaitions
- anticonvulsant
- sedative
- amenstic
- anxiolytic
Pearls
- has 1kcal/ml : energy
- dose-dependent sedation effect: titrate up and down
- rapid onset of action: accumulated in lipid tissue
- duration of action longer with increased use
Toxicities
- egg, soybean or sulfite allergy = avoid
- hypertriglyceridemia: dont use if TG > 200ish. (check baseline and Q72H)
- myoclonus
- hemodynamic (RR depression and hypotension)
- green urine
Propofol Related Infusion Syndrome
- essentailly: organ failure & at this point you do supportie care
- metabolic acidosis
- arrythmia
- AKI
- hyperlipidemia
- rhabdo.
- hepatic dysfunction
Refractory Status epi. : treatment once seizures subsided
once seizures stopped: need to have a maitnence plan in place
- phenytoin or other drug used during urgent treatment should be continued
- slowly wean off continuous (midazolam or propofol)
define status epi
any seizure lasting > 5 minutes
or 2+ seizures without completel recovery to baseline functioning between them
