Status Epilepticus - Block 1

Question 2

What is SE?

Answer 2

continuous seizure activity (≥ 5 minutes) + risk of long-term consequences (≥ 30 minutes)

Question 3

What is the most common form of SE?

Answer 3

generalized convulsive status epilepticus (GCSE)

Question 4

What is characterized as epileptic twilight with altered consciousness?

Answer 4

nonconvulsive status epilepticus (NCSE)

Question 5

What is the tx for nonconvulsive status epilepticus (NCSE)?

Answer 5

Benzodiazepines remain drugs of choice
* 2nd line: IV phenytoin, valproate, levetiracetam
* Lacosamide or topiramate can be tried in nonresponders

Question 6

What are the phases of GCSE?

Answer 6

Question 7

What are the causes of SE?

Answer 7

Neonates: drug withdrawl, pyroxidine def
1 YO: Acute encephalopathy and metabolic disorders
Young children: Fever/viral illness
Adult: Cerebrovascular dx, rapid antiseizure med withdrawl, low antiseizure med levels

Question 8

What causes GCSE?

l[\

Answer 8

1. Imbalance between excitatory and inhibitoiry neurotransmission
2. is largely caused by glutamate acting on postsynaptic N-methyl-D-aspartate (NMDA) and α-amino-3-hydroxy-5-methyl-isoxazole-4-propionate (AMPA)/kainate receptors

Question 9

What are the clincal implications of GCSE?

Answer 9

A prolonged seizure can destroy neurons:
* (First 30 min): Hypertension, tachycardia, and cardiac arrhythmias
* Hyperglycemic initially and then serum glucose begins to fall
* Muscle contractions  rhabdomyolysis with secondary hyperkalemia and acute tubular necrosis
* Airway obstruction  cyanotic or hypoxic
* Increase in salivation and tracheal and pulmonary secretions  aspiration pneumonia

Severe complications begin to arise (hypotension, hypoglycemia, hypoxia, severe metabolic disturbances)
Convulsive SE (CSE) lasting 1 hour or more increases morbidity by 10-fold

Question 10

Lab test for SE?

Answer 10

1. CBC
2. Serum
3. Urinalysis
4. Blood cultrue
5. ABG
6. Serum drug

Question 11

Non pharm to stabilize patients?

Answer 11

1. Time of seizure onset
2. Vital signs
3. Adequate and protected airway
4. IV access
5. Tx for hyperthermia (cooling blanket)

Question 12

Pharm for SE?

Answer 12

Initial-therapy phase (5-20 minutes) - impending
Second-therapy phase (20-40 minutes) - established
Third-therapy phase (40-60 minutes) - refractory

Question 13

What occurs in the initial tx phase?

Answer 13

BENZOS
Initial toc: IM midazolam, IV lorazepam, or IV diazepam
* Patients chronically on a benzodiazepine (eg, clobazam and clonazepam) might have developed tolerance and could require large doses

Alt: IV phenobarbital

Question 14

What benzo is typically the drug of choice for most clinicians?

Answer 14

Lorazepam

Question 15

What is the consideration when using diazepam?

Answer 15

Lipophilic and redistribution: efficacy is about 30 min and thus a longer-acting anticonvulsant should be administered afterwards

Question 16

What is the consideration when using midazolam?

Answer 16

Maintenance doses must be given by continuous infusion due to short half-life

Question 17

What is given to patient once discharged?

Answer 17

IM midazolam
Intranasal (IN) and buccal midazolam
Per rectum (PR) and IN diazepam

Question 18

What are the second therapy agents?

Answer 18

1. Hdantoin (Phenytoin or fosphenytoin)
2. Valproate
3. Phenobarbital
4. Levetiracetam
5. Lacosamide

Question 19

When should phenobarbital be used?

Answer 19

Paatients have failed other second therapy phase agents

Question 20

Third phase tx?

Answer 20

Anesthetic doses of midazolam, pentobarbital, or propofol may be used:
* If the patient is not already intubated and mechanically ventilated, this is required prior to administration of anesthetics – along with contin EEG

Question 21

Considerations of midazolam?

Answer 21

1. If used, it should always be combined with another drug that acts at a different site and ideally initiated within 30 min
2. No specific protocol for tapering of midazolam; some suggest a seizure-free period of 24 to 48 hours followed by decreasing by 1 to 2 mcg/kg/min every 15 minutes
3. Return to consciousness more rapidly due to short half-life

Question 22

Considerations of Pentobarbital or thiopental (short-acting barbiturates)

Answer 22

1. Although no controlled trials to support this practice, overall response rates were found to be significantly greater in those treated with pentobarbital compared to midazolam or propofol
2. Potent hepatic enzyme inducer -> doses of most concurrent anticonvulsants will need to be larger than usual maintenance doses

Question 23

Proprafol considerations?

Answer 23

1. Extremely lipid soluble, has a large volume of distribution, has a very rapid onset of action and its extremely short half-life
2. Prolonged infusions greater than 4 mg/kg/hr have been associated with propofol-related infusion syndrome (PRIS)

Question 24

What to use in super refractory GCSE?

Answer 24

1. Ketamine
2. Lidocaine
3. Inhaled anesthetics
4. Immunomodulating tx
5. Controlled mild hypothermia

Question 25

Ketamine

MOA, ADR

Answer 25

MOA: Noncompetitive antagonist of glutamatergic N-methyl-D-aspartate (NMDA) receptors
ADR: hallucinations upon awakening, increased salivation, and increased intraocular and intracranial pressure

Question 26

Lidocaine consdieration?

Answer 26

Serum concentrations and ECG should be monitored to avoid drug accumulation and toxicity

Question 27

Monitoring of SE?

Answer 27

1. EEG
2. Vital signs
3. Infusion site

Question 28

Algorithm for convulsive SE?

Answer 28