Status Epilepticus Flashcards
What is the definition of SE?
Seizure lasting > 30min of either:
Continuous seizure activity
OR
2 or more sequential seizures w/o an intervening period of consciousness between seizures
What is the least common form of SE?
NCSE (nonconvulsive SE)
What are the most common and severe form of SE?
GCSE
What are the types of seizures in GCSE?
Tonic clonic
What are type I GCSE?
Not associated with structural lesions
What causes type I GCSE?
Infection (pediatrics)
Low AED levels
What are type II GCSE?
Associated with structural lesions
What causes type II GCSE?
Congenital malformations (pediatrics) CVA (adults)
Which type of GCSE has the worst prognosis?
Type II
What are most episodes of SE d/t?
Acute anticonvulsant WD
Metabolic d/o or concurrent illness
Progression of a pre-existing neurologic dz
What are the causes of GCSE in < 1yo?
Acute encephalopathy
Metabolic disorders
What are the causes of GCSE in adults?
CVA dz
WD of anticonvulsants
Low anticonvulsant serum concentrations
What are the phases of SE?
Phase I - Occurs in the 1st 30 minutes of seizure
Phase II - Patient begins to decompensate
What is the clinical presentation of SE?
Impaired consciousness
Disorientation once GCSE is controlled
Pain associated with secondary injuries
What are the early signs of SE?
Acute injuries/CNS insults that cause extensor/flexor posturing
Hypothermia/fever which may indicate underlying illness such as sepsis or meningitis
Evidence of head/other CNS injury
Generalized convulsions, muscle contractions, spasms
Incontinence
Normal BP/hypotension
Respiratory compromise
What are late signs of SE?
Clinical seizures may or may not be apparent Pulmonary edema w/respiratory failure Cardiac failure Hypo/hypertension DIC/multi-organ failure
What are lab tests for SE diagnosis
CBC w/diff CMP Urine drug/alcohol screen Blood cultures ABG Drug concentration
What are other diagnostic tests for SE?
LP EEG CT MRI Radiograph ECG
What are the short term goals for SE?
Immediate termination of all clinical and electrical seizure activity
No clinically significant SE
Lack of recurrent seizure activity
What are the long term goals of SE?
Minimize and/or avoid likelihood of pharmacoresistant epilepsy
Minimize and/or avoid the development of neurologic sequelae
What are the pharmacologic treatment goals?
Patient stabilization
Accurate diagnosis of the subtype of GCSE and identification of precipitating factors
Termination of clinical and electrical seizures
Prevention of seizure recurrence
What are the 1st line therapies for SE?
Benzos IV
Lorazepam, diazepam, midazolam
What is administered after benzos in SE?
Phenytoin
Fosphenytoin
Phenobarbital
Keppra
How does phenytoin work in SE?
Stabilizes neuronal membranes by decreasing na influx/increasing na efflux through VSCC blockade
What must be monitored with pheny?
VS
ECG
pH
What is a AE of pheny?
Purple glove syndrome
What is the max infusion rate of phenytoin?
50mg/min
What is the dose of fosphenytoin?
15-20 PE/kg
What are dose and infusion time related in fosphenytoin
Paresthesia and pruritus
What are AE if fosphenytoin?
Nystagmus
Dizziness
Ataxia
When is phenobarb recommended in SE?
Failure of benzo plus phenytoin
What is refractory GCSE?
Adequate doses of benzo, phenytoin or fosphenytoin, or phenobarb have failed
What is the benzo of choice in refractory GCSE?
Midazolam
What would increase the rate of infusion of midazolam?
Tachyphylaxis
What are the treatment of refractory GCSE?
Benzo Medically induced coma VPA Keppra and Lacosamide Propofol
What are the treatments for super refractory SE?
Oral topamax
Ketamine
IV lidocaine
What drugs are used for medically induced comas?
Pentobarbital
Thiopental
Is VPA FDA approved for GCSE?
No, but used in ped and adults
What is propofol infusion syndrome?
Respiratory depression, cerebral depression and bradycardia
What is ketamine?
Non-competitive NMDA receptor antagonist that blocks glutamate
