Status Epilepticus / acute seizure management Flashcards
Syndromes commonly associated with NCSE:
- Neonatal / Infantile (3)
- Childhood ONLY (3)
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
Epilepsy Conditions commonly associated with NCSE:
- Childhood OR Adult (6)
- 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
Top 5 causes of Status Epilepticus: Adult
CVA (25%)
Changes in ASM (19%)
EtOH/Drugs (12%)
Anoxia (11%)
Metabolic (9%)
Top 5 causes of Status epilepticus: Pediatric
Fever / infection (35%)
Changes in ASM (20%)
Crytpogenic (9%)
Metabolic (8%)
Congenital (7%)
Medications known to cause SE
Non-ASM (8)
ASM (3)
LIIT FACTs about TV
Non-ASM
- Lithium
- Isoniazid
- Ifosfamide
- Tacrolimus
- Flumazenil
- Amoxapine
- Cyclosporine
- Theophylline
ASM
- Tiagabine
- Vigabatrin
- Valproate
Paraneoplastic Cancers commonly associated with SE (3) (and associated Antibodies)
Hu (small Cell lung Ca)
Ma2 (sslc, testicular germ-cell carcinoma)
CRMP5 (sslc / thymoma)
Autoimmune CONDITIONS associated with Status epilepticus (3)
- Hashimoto’s Thyroiditis
- Systempic Lupus (SLE)
- Rasmussen’s encephalitis
Autoimmune RECEPTORS associated with status epilepticus (3)
- Thyroid microsomal antibodies
-NMDA receptor
-Anti-NR2A
Stages of Status Epilepticus (5)
Stage 1 (early)
- Incipient: 5 minutes
- Early: 5-10 minute
Stage 2 (established)
- 30-60 minutes
Stage 3 (refractory)
- 60 minutes
Complications of Tonic-clonic Status epilepticus:
Cerebral
(4, last one with 3 subtypes)
- Hypoxic / metabolic damage
- Excitatoxic Damage
- Edema / Increased ICP
- CVA
- Venous thrombosis
- Infarction
- hemorrhage
Complications of Tonic-clonic Status epilepticus:
Cardiac (3)
Hypo/Hypertension
Cardiac Failure / shock
Tachy-Brady-arrhythmia / arrest
Complications of Tonic-clonic Status epilepticus: Respiratory (5)
- Apnea / Respiratory failure
- Hypertension
- Aspiration
- Pneumonia
- Pulmonary Embolus
Complications of Tonic-clonic Status epilepticus:
Autonomic
- Sweating
- Hyperthermia
Complications of Tonic-clonic Status epilepticus:
Metabolic / systemic (10)
HA, Da FIR
- Hypoglycemia
- Hyponatremia
- Hypokalemia
- Acidosis
- Acute renal Failure
- Acute Hepatic Failure
- DIC
- Rhabdomyolysis
- Infections
- Fractures
Peri-Ictal MRI imaging changes for Status Epilepticus
- Ipsi/Bilateral thalamic lesions (mass effect)
- Contralateral Cerebellar diaschisis (hippocampal swelling)
- Splenium abnormalities (focal cortical lesion)
- PRES (migratory focal cortical lesions
This patient is in status, what are we seeing and what kind of seizures is he having?
Increased T2 signal in R hemisphere (Epilepsia partialis continua
This patient is in status, what are we seeing and what kind of seizures is he having?
Hippocampal swelling (bitemporal status)
This patient is in status, what are we seeing and what kind of seizures is he having?
Axial DWI showing expanded and hyperintense splenium (bi-temporal status epilepticus)
This patient is in status, what are we seeing and what kind of seizures is he having?
Cerebellar diaschisis, right hemispheric SE. Hey seem
This patient is in status, what are we seeing and what kind of seizures is he having?
Gyral pattern of restricted Diffusion + thalamic (pulvinar) change in left hemispheric status epilepticus
Dosing for status epilepticus, adult and pediatric
IV lorazepam
IM Midazolam
IV diazepam
Rectal diazepam
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
Infusions for Status Epilepticus: Propofol
Dose, Bolus:
Infusion rate:
SE control rate:
Infusions for Status Epilepticus: Propofol
Dose, Bolus: 1-2 mg/kg
Infusion rate: 5-10 mg/kg/h
SE control rate: 68%
Infusions for Status Epilepticus: midazolam
Dose, Bolus:
Infusion rate:
SE control rate:
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%
Infusions for Status Epilepticus: Pentobarbital
Dose, Bolus:
Infusion rate:
SE control rate:
Infusions for Status Epilepticus: Pentobarbital
Dose, Bolus: 5-20 mg/kg
Infusion rate: 0.1-3 mg/kg/h
SE control rate: 64%
Dosing for Status Epilepticus: phenytoin
Infusion Rate: adult
Infusion Rate: Pediatric
Both 20 mg/kg
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.
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.
Dosing for status epilepticus: Levetiracetam
Adult:
Pediatric:
Neither officially established:
Adult: 2000 mg - 4000 mg
Pediatric: 30-60 mg/kg/day
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
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%
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
Half life of Propofol (2)
2 hours (but rapid offset due to rapid distribution into peripheral tissues
Side effects to take into consideration with Propofol for SE
Hypotension
metabolic acidosis
pneumonia
Propofol infusion syndrome
Features that can increase risk of Propofol Infusion syndrome
> 4 mg/kg/h for more than 24 hours
- Co-treatment with catecholamines and sterois
Signs of Propofol infusion syndrome (4)
- unexplained lactic acidosis
- rhabdomyolysis (elevated CK)
- hypertriglyceridemia
- Widespread EKG changes
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
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%
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
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%
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%
Percentage of children with Status epilepticus who:
Develop subsequent epilepsy
Neurodevelopmental decline (+ caveat)
Develop epilepsy: 25-40%
Neurodevelopmental decline 35% of SE > 30 minutes
Percent of (adult) altered mental status patients in ICU with subclinical seizures
20%
Percent of patients with symptomatic status epilepticus who will develop seizure disorder
15-30%
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
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
mortality rates for status epilepticus by seizure type:
- myoclonic
- Generalized tonic-clonic
- simpler partial
Myoclonic: 50-85%
GTC: 30%
Simple partial: 15-25%
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%
Dosing for status epilepticus: Valproate
Adult:
Pediatric
Dosing for status epilepticus: Valproate
Adult: 15-30 mg/kg
Pediatric: 20-40 mg/kg
