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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
Dosing for Status Epilepticus: phenytoin Infusion Rate: adult Infusion Rate: Pediatric
Both 20 mg/kg
26
Why is fosphenytoin preferred over phenytoin
Faster infusion rate (up to 100 mg/min as opposed to 50 mg/min), lower risk of infusion reaction.
27
Dosing for status epilepticus: Phenobarbital IV infusion rate: Adult IV infusion rate: pediatric
Adult: 15-20 mg/kg (no more than 100 mg/min) Pedaitric: ame 20 mg/min as in neonates and infants.
28
Dosing for status epilepticus: Levetiracetam Adult: Pediatric:
Neither officially established: Adult: 2000 mg - 4000 mg Pediatric: 30-60 mg/kg/day
29
Pathophysiology of refractory Status Epilepticus. When does pharmacoresistance develop? What causes it?
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
Super-refractory status epilepticus: Definition: % of SE:
Super-refractory status epilepticus: Definition: >24 hours after onset of anesthesia or SE recurrence after tapering of anesthesia % of SE: 10-15%
31
Benefits of induced Coma for SE (other than stopping seizure): 3
- lowers metabolic activity of brain tissue - Removes energy mismatch between brain tissue energy use and supply - allows neuronal recovery
32
Half life of Propofol (2)
2 hours (but rapid offset due to rapid distribution into peripheral tissues
33
Side effects to take into consideration with Propofol for SE
Hypotension metabolic acidosis pneumonia Propofol infusion syndrome
34
Features that can increase risk of Propofol Infusion syndrome
>4 mg/kg/h for more than 24 hours - Co-treatment with catecholamines and sterois
35
Signs of Propofol infusion syndrome (4)
- unexplained lactic acidosis - rhabdomyolysis (elevated CK) - hypertriglyceridemia - Widespread EKG changes
36
Non-obvious side effects to consider for pentobarbital 2 generic 2 GI
(highest incidence of systemic complications) - hypotension - splanchnic hypoperfusion (gastric, pancreatic, hepatic sequelae) - immunosuppression - reduced GI motility
37
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
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
Prognosis in Status Epilepticus: Factors increasing mortality (5) Factors reducing mortality (2)
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
Prognosis in Status Epilepticus: % of adults with mild neurologic deficits % of adults with major neurologic deficits % of adults who recover to baseline: 35%
Minor deficits: 15% Major deficits: 15% Recover to baseline: 35%
40
Prognosis in REFRACTORY Status Epilepticus Mortality, Children Mortality, Adults Return to baseline, Children Return to baseline, Adults
Prognosis in REFRACTORY Status Epilepticus Mortality, Children: 15-45% Mortality, Adults: 40-50% Return to baseline, Children: 32% Return to baseline, Adults: 28%
41
Percentage of children with Status epilepticus who: Develop subsequent epilepsy Neurodevelopmental decline (+ caveat)
Develop epilepsy: 25-40% Neurodevelopmental decline 35% of SE > 30 minutes
42
Percent of (adult) altered mental status patients in ICU with subclinical seizures
20%
43
Percent of patients with symptomatic status epilepticus who will develop seizure disorder
15-30%
44
Degrees of Absence status (Description and relative % of cases. Grade I Grade II Grade III Grade IV
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
Subtypes of myoclonic status (2, 2 bullets each)
Pure primary - generalized bilateral synchronous jerks - Preservation of consciousness Symptomatic - asymmetric or asynchronous jerks - variable impairment of consciousness
46
mortality rates for status epilepticus by seizure type: - myoclonic - Generalized tonic-clonic - simpler partial
Myoclonic: 50-85% GTC: 30% Simple partial: 15-25%
47
48
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
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
Dosing for status epilepticus: Valproate Adult: Pediatric
Dosing for status epilepticus: Valproate Adult: 15-30 mg/kg Pediatric: 20-40 mg/kg

Epilepsy Borrowed Decks (57 decks)

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