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Epilepsy Borrowed Decks > Status Epilepticus / acute seizure management > Flashcards

Status Epilepticus / acute seizure management Flashcards

1
Q

Syndromes commonly associated with NCSE:
- Neonatal / Infantile (3)
- Childhood ONLY (3)

A

Conditions commonly associated with NCSE:
- Neonatal / Infantile
- Otahara syndrome
- West syndrome
- Severe myoclonic epileptic encephalopathy of infancy (SMEI) / Dravet
- Childhood
- (occipital) Early-onset Panayiotopoulos syndrome
- Other childhood EI’s
- ESES / Landau-Kleffner

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2
Q

Epilepsy Conditions commonly associated with NCSE:
- Childhood OR Adult (6)

A
  • LGS (atypical absence and tonic)
  • Complex partial SE (limbic and non-limbic)
  • Typical absence SE
  • Postictal phase from GTC
  • Subtle SE (i.e. myoclonic SE)
  • Aura continua
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3
Q

Top 5 causes of Status Epilepticus: Adult

A

CVA (25%)
Changes in ASM (19%)
EtOH/Drugs (12%)
Anoxia (11%)
Metabolic (9%)

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4
Q

Top 5 causes of Status epilepticus: Pediatric

A

Fever / infection (35%)
Changes in ASM (20%)
Crytpogenic (9%)
Metabolic (8%)
Congenital (7%)

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5
Q

Medications known to cause SE
Non-ASM (8)
ASM (3)

A

LIIT FACTs about TV
Non-ASM
- Lithium
- Isoniazid
- Ifosfamide
- Tacrolimus
- Flumazenil
- Amoxapine
- Cyclosporine
- Theophylline
ASM
- Tiagabine
- Vigabatrin
- Valproate

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6
Q

Paraneoplastic Cancers commonly associated with SE (3) (and associated Antibodies)

A

Hu (small Cell lung Ca)
Ma2 (sslc, testicular germ-cell carcinoma)
CRMP5 (sslc / thymoma)

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7
Q

Autoimmune CONDITIONS associated with Status epilepticus (3)

A
  • Hashimoto’s Thyroiditis
  • Systempic Lupus (SLE)
  • Rasmussen’s encephalitis
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8
Q

Autoimmune RECEPTORS associated with status epilepticus (3)

A
  • Thyroid microsomal antibodies
    -NMDA receptor
    -Anti-NR2A
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9
Q

Stages of Status Epilepticus (5)

A

Stage 1 (early)
- Incipient: 5 minutes
- Early: 5-10 minute
Stage 2 (established)
- 30-60 minutes
Stage 3 (refractory)
- 60 minutes

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10
Q

Complications of Tonic-clonic Status epilepticus:
Cerebral
(4, last one with 3 subtypes)

A
  • Hypoxic / metabolic damage
  • Excitatoxic Damage
  • Edema / Increased ICP
  • CVA
    • Venous thrombosis
    • Infarction
    • hemorrhage
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11
Q

Complications of Tonic-clonic Status epilepticus:
Cardiac (3)

A

Hypo/Hypertension
Cardiac Failure / shock
Tachy-Brady-arrhythmia / arrest

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12
Q

Complications of Tonic-clonic Status epilepticus: Respiratory (5)

A
  • Apnea / Respiratory failure
  • Hypertension
  • Aspiration
  • Pneumonia
  • Pulmonary Embolus
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13
Q

Complications of Tonic-clonic Status epilepticus:
Autonomic

A
  • Sweating
  • Hyperthermia
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14
Q

Complications of Tonic-clonic Status epilepticus:
Metabolic / systemic (10)

A

HA, Da FIR
- Hypoglycemia
- Hyponatremia
- Hypokalemia
- Acidosis
- Acute renal Failure
- Acute Hepatic Failure
- DIC
- Rhabdomyolysis
- Infections
- Fractures

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15
Q

Peri-Ictal MRI imaging changes for Status Epilepticus

A
  • Ipsi/Bilateral thalamic lesions (mass effect)
  • Contralateral Cerebellar diaschisis (hippocampal swelling)
  • Splenium abnormalities (focal cortical lesion)
  • PRES (migratory focal cortical lesions
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16
Q

This patient is in status, what are we seeing and what kind of seizures is he having?

A

Increased T2 signal in R hemisphere (Epilepsia partialis continua

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17
Q

This patient is in status, what are we seeing and what kind of seizures is he having?

A

Hippocampal swelling (bitemporal status)

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18
Q

This patient is in status, what are we seeing and what kind of seizures is he having?

A

Axial DWI showing expanded and hyperintense splenium (bi-temporal status epilepticus)

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19
Q

This patient is in status, what are we seeing and what kind of seizures is he having?

A

Cerebellar diaschisis, right hemispheric SE. Hey seem

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20
Q

This patient is in status, what are we seeing and what kind of seizures is he having?

A

Gyral pattern of restricted Diffusion + thalamic (pulvinar) change in left hemispheric status epilepticus

21
Q

Dosing for status epilepticus, adult and pediatric
IV lorazepam
IM Midazolam
IV diazepam
Rectal diazepam

A

IV Lorazepam
- Adult: 4 mg
- Pediatric: 0.1 mg/kg
IM midazolam
- Adult: 5-10 mg
- Pediatric: 0.15-0.3 mg/kg
IV Diazepam
- Adult: 10-20 mg
- Pediatric: 0.25-0.5 mg/kg
Rectal diazepam
- Adult 10-20 mg
- Pediatric 0.5-0.75 mg/kg

22
Q

Infusions for Status Epilepticus: Propofol
Dose, Bolus:
Infusion rate:
SE control rate:

A

Infusions for Status Epilepticus: Propofol
Dose, Bolus: 1-2 mg/kg
Infusion rate: 5-10 mg/kg/h
SE control rate: 68%

23
Q

Infusions for Status Epilepticus: midazolam
Dose, Bolus:
Infusion rate:
SE control rate:

A

Infusions for Status Epilepticus: midazolam
Dose, Bolus: 0.1-0.3 mg/kg
Infusion rate: 0.05-0.4 mg/kg/h
SE control rate: 78%

24
Q

Infusions for Status Epilepticus: Pentobarbital
Dose, Bolus:
Infusion rate:
SE control rate:

A

Infusions for Status Epilepticus: Pentobarbital
Dose, Bolus: 5-20 mg/kg
Infusion rate: 0.1-3 mg/kg/h
SE control rate: 64%

25
Q

Dosing for Status Epilepticus: phenytoin
Infusion Rate: adult
Infusion Rate: Pediatric

A

Both 20 mg/kg

26
Q

Why is fosphenytoin preferred over phenytoin

A

Faster infusion rate (up to 100 mg/min as opposed to 50 mg/min), lower risk of infusion reaction.

27
Q

Dosing for status epilepticus: Phenobarbital
IV infusion rate: Adult
IV infusion rate: pediatric

A

Adult: 15-20 mg/kg (no more than 100 mg/min)
Pedaitric: ame 20 mg/min as in neonates and infants.

28
Q

Dosing for status epilepticus: Levetiracetam
Adult:
Pediatric:

A

Neither officially established:
Adult: 2000 mg - 4000 mg
Pediatric: 30-60 mg/kg/day

29
Q

Pathophysiology of refractory Status Epilepticus.
When does pharmacoresistance develop?
What causes it?

A

Pathophysiology of refractory Status Epilepticus.
When does pharmacoresistance develop? 30-45 minutes
What causes it?:
- Seizure-induced internalization of synaptic GABA-A receptor (benzos are less effective)
- Simultaneous externalization of AMPA/NMDA receptors

30
Q

Super-refractory status epilepticus:
Definition:
% of SE:

A

Super-refractory status epilepticus:
Definition: >24 hours after onset of anesthesia or SE recurrence after tapering of anesthesia
% of SE: 10-15%

31
Q

Benefits of induced Coma for SE (other than stopping seizure): 3

A
  • lowers metabolic activity of brain tissue
  • Removes energy mismatch between brain tissue energy use and supply
  • allows neuronal recovery
32
Q

Half life of Propofol (2)

A

2 hours (but rapid offset due to rapid distribution into peripheral tissues

33
Q

Side effects to take into consideration with Propofol for SE

A

Hypotension
metabolic acidosis
pneumonia
Propofol infusion syndrome

34
Q

Features that can increase risk of Propofol Infusion syndrome

A

> 4 mg/kg/h for more than 24 hours
- Co-treatment with catecholamines and sterois

35
Q

Signs of Propofol infusion syndrome (4)

A
  • unexplained lactic acidosis
  • rhabdomyolysis (elevated CK)
  • hypertriglyceridemia
  • Widespread EKG changes
36
Q

Non-obvious side effects to consider for pentobarbital
2 generic
2 GI

A

(highest incidence of systemic complications)
- hypotension
- splanchnic hypoperfusion (gastric, pancreatic, hepatic sequelae)
- immunosuppression
- reduced GI motility

37
Q

Prognosis in Status Epilepticus:
Overall mortality: Children (short term)
Overall mortality: Children (long term)
Overall mortality: young adults
Overall mortality: Elderly
Overall mortality: 30-60 minutes
Overall mortality: >1 hour

A

Prognosis in Status Epilepticus:
Overall mortality: Children (short term)- 3-6%
Overall mortality: Children (long term) - 6%
Overall mortality: young adults - 14%
Overall mortality: Elderly: 38%
Overall mortality: 30-60 minutes - 3%
Overall mortality: >1 hour 32%

38
Q

Prognosis in Status Epilepticus:
Factors increasing mortality (5)
Factors reducing mortality (2)

A

Factors increasing mortality
- acute precipitant
- acute symptomatic epilepsy
- after anoxic brain injury
- in the elderly
- > 24Hours
Factors reducing mortality:
- Alcohol withdrawal seizures
- Status due to ASM non-compliance

39
Q

Prognosis in Status Epilepticus:
% of adults with mild neurologic deficits
% of adults with major neurologic deficits
% of adults who recover to baseline: 35%

A

Minor deficits: 15%
Major deficits: 15%
Recover to baseline: 35%

40
Q

Prognosis in REFRACTORY Status Epilepticus
Mortality, Children
Mortality, Adults
Return to baseline, Children
Return to baseline, Adults

A

Prognosis in REFRACTORY Status Epilepticus
Mortality, Children: 15-45%
Mortality, Adults: 40-50%
Return to baseline, Children: 32%
Return to baseline, Adults: 28%

41
Q

Percentage of children with Status epilepticus who:
Develop subsequent epilepsy
Neurodevelopmental decline (+ caveat)

A

Develop epilepsy: 25-40%
Neurodevelopmental decline 35% of SE > 30 minutes

42
Q

Percent of (adult) altered mental status patients in ICU with subclinical seizures

A

20%

43
Q

Percent of patients with symptomatic status epilepticus who will develop seizure disorder

A

15-30%

44
Q

Degrees of Absence status (Description and relative % of cases.
Grade I
Grade II
Grade III
Grade IV

A

Grade 1 (20%)
- Slight clouding of consciousness
- subtle enough you might not know
Grade II (65%)
- marked clouding of consciousness
- disorientation
- delayed responsiveness
Grade III (7%)
- Profound clouding
- motionless behavior, inability to move / feed
Grade IV (8%)
- “lethargic stupor”
- motionless staring
- upward eye deviation
- incontinence

45
Q

Subtypes of myoclonic status (2, 2 bullets each)

A

Pure primary
- generalized bilateral synchronous jerks
- Preservation of consciousness
Symptomatic
- asymmetric or asynchronous jerks
- variable impairment of consciousness

46
Q

mortality rates for status epilepticus by seizure type:
- myoclonic
- Generalized tonic-clonic
- simpler partial

A

Myoclonic: 50-85%
GTC: 30%
Simple partial: 15-25%

47
Q
A
48
Q

Refractory Status Epilepticus:
Definition:
% of cases, all SE
% of cases evolving from Convulsive to non-convulsive: Adult
% of cases evolving from Convulsive to non-convulsive: pediatric

A

Refractory Status Epilepticus:
Definition: Seizure > 1 hour despite rescue
% of cases, all SE: 35%
% of cases evolving from Convulsive to non-convulsive: Adult: 15%
% of cases evolving from Convulsive to non-convulsive: pediatric: 25%

49
Q

Dosing for status epilepticus: Valproate
Adult:
Pediatric

A

Dosing for status epilepticus: Valproate
Adult: 15-30 mg/kg
Pediatric: 20-40 mg/kg

Epilepsy Borrowed Decks (57 decks)

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