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MJ- Pharm Exam 3 > Status Epilepticus- MJ > Flashcards

Status Epilepticus- MJ Flashcards

1
Q

In general, what is the order of treatment for a person with Status Epilepticus?

(I got this from a youtube video but it aligns with her info)

A
  1. 1st line= Benzos every 5min
    * Lorazepam IV (1st line) or Midazolam (IM/IN) or PR diazepam
  2. If still seizing: Phenytoin or IV Phenobarbital/valproic acid
  3. Last resort: General anesthesia, intubation and EEG monitoring
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2
Q

Generalized convulsive status epilepticus (GCSE) is:

  • Any recurrent or continuous seizure activity lasting longer than ____ minutes and patient does not regain baseline mental status
  • Any seizure that does not stop within ____ minutes should be aggressively treated as impending SE.
A
  • 30 minutes
  • 5 minutes
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3
Q

T/F: Generalized convulsive status epilepticus (GCSE) is a life threatening medical emergency?

A

TRUE!

•Any seizure that does not stop within 5 minutes should be aggressively treated as impending SE.

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4
Q

Pathophysiology of GCSE:

Seizure initiation caused by an imbalance between ______ and _____ neurotransmission

A

Excitatory (Glutamate, Ca, Na, etc)

and

inhibitory (GABA, adenosine, K, opioide peptides, Galantin, etc) neurotransmission

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5
Q

The pathophysiology of GCSE is seizure initiation caused by an imbalance b/w excitatory (Glutamate) and inhibitory neurotransmission (GABA).

Sustained depolarization can result in what?

A

Neuronal death

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6
Q

The following pathophysiology is asosciated with early or late seizure?

  • Marked increases in plasma epinephrine, norepinephrine, steroid concentrations
    • HTN, tachycardia, cardiac arrhythmias
  • Muscle contractions and hypoxia
    • Acidosis
    • Hypotension, shock
    • Rhabdomyolysis, and secondary hyperkalemia
    • Acute tubular necrosis may ensue
A

Early (0-30 minutes)

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7
Q

The following pathophysiology is asosciated with early or late seizure?

–Decompensation of patient

–Hypotensive with compromised cerebral blood flow

–Serum glucose may be normal or decreased

–Hyperthermia, respiratory deterioration, hypoxia, and ventilatory failure may develop

A

Later (30+ minutes)

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8
Q

T/F: In prolonged seizures, motor activity may cease, but electrical seizures may persist

A

True

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9
Q

What are the 5 goals of treatment of Generalized convulsive status epilepticus (GCSE)

A
  1. Identify GCSE subtype and precipitating factors
  2. Terminate clinical and electrical seizure activity ASAP, and preserve cardiorespiratory function
  3. Minimize side effects
  4. Prevent recurrent seizures
  5. Avoid pharmacoresistant epilepsy and/or neurologic sequelae
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10
Q

What is the treatment of Impending GCSE (0-30 minutes)?

A
  • Lorazepam* (preferred benzo)
    • efficacy and long duration of action in the CNS
  • Midazolam (preferred for IM, intranasal (IN) and buccal admin)
  • Diazepam (rectal- caregiver option)

“Love Mi Dog”

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11
Q

What are the established first line GCSE treatments (30-60 min)?

A

•Hydantoins

  • phenytoin and fosphenytoin
  • long-acting anticonvulsants
  • given concurrently with benzodiazepines
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12
Q

What is the treatment for refractory GCSE (>120min)?

A

•Treatment then First line: (want to anesthetize)

  • Anesthetic doses of midazolam
  • Pentobarbital
  • Propofol
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13
Q

What are 2nd and 3rd line established GCSE treatments (30-60 minutes)?

A

Second line:

  • Phenobarbitol
  • valproate

Third line:

  • Lacosamide
  • Levatiracetam
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14
Q

What makes GCSE considered to be refractory?

A

•GCSE is considered to be refractory when seizure is not controlled by two anticonvulsants

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15
Q

What are the 5 final tx options for super-refractory GCSE?

A
  1. Ketamine
  2. Hypothermia
  3. Lidocaine (prob wouldn’t give)
  4. Topiramate (give nasogastrically- crush tabs into water)
  5. Inhaled anesthetics (not used until other approaches fail)
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16
Q

What is the Mechanism of Ketamine in the tx of super-refractory GCSE?

A
  • may increase the # of NMDA receptor to increase glutamate’s effect
  • may also possess an antagonistic effect on NMDA receptors
17
Q

The following is the mechanism of what final tx option for super-refractory GCSE?

  • reduces excitatory transmission and epileptic discharges and reduces brain edema, cerebral metabolic rate, oxygen utilization, and ATP consumption
  • core body temp of ~32°C -35°C is targeted for at least 24 to 48 hours
  • significantly reduce the clearance of several drugs, including anesthetics and antiepileptics
A
  • Hypothermia
18
Q

The following are final options for what type of GCSE?

  • Immunomodulating therapy
    • corticosteroids and IV immune globulin
  • Ketogenic diet
  • Vagal nerve stimulation (grade D)
A

Super-refractory GCSE final options

19
Q
A
20
Q

What has animal data suggested regarding the use of Immunomodulating therapy of super-refractory GCSE

A

suggest the development of super-refractory GCSE may be due to antibodies directed against the voltage-gated potassium channels and the NMDA receptor

21
Q

What are the 2 ADEs of Diazepam and how do you monitor?

A

ADEs: Hypotension and cardiac arrhythmias

Monitor: Vital signs and ECG during administration

22
Q

Which medication?

  • Propylene glycol causes hypotension and cardiac arrhythmias when administered too rapidly
  • hypotension may occur with large doses
A

Diazepam

(Propylene glycol stabilizes drug but too much can cause lactic acidosis)

23
Q

What are the 4 ADEs of Fosphenytoin and how do you monitor?

A
  1. Hypotension
  2. Cardiac arrhythmias
  3. Paresthesia
  4. Pruritus

Monitor vital signs and ECG during administration

24
Q

Which med?

  • Hypotension is less than that noted with phenytoin, as this product does not contain propylene glycol
  • Pruritus generally involves the face and groin areas, is dose and rate related, and subsides 5-10 minutes after infusion
A

Fosphenytoin

25
Q

What are the 5 ADEs of Lidocaine?

“Save The Vodka For Luis”

A
  1. Fasciculations
  2. Visual disturbances
  3. Tinnitus
  4. Seizures

“Save The Vodka For Luis”

26
Q

The following are ADEs of which med? How do you monitor?

  1. Apnea
  2. Hypotension
  3. Bradycardia
  4. Cardiac arrest
  5. Respiratory depression
  6. Metabolic acidosis
  7. Renal toxicity
A

Monitor:

  • Vital signs and ECG during administration
  • HCO3 and serum creatinine
  • Cumulative dose of propylene glycol
27
Q

Which med?

  • Accumulation of propylene glycol during prolong continuous infusions may cause acidosis
A

Lorazepam

(propylene glycol stabilizes drug but too much causes lactic acidosis)

28
Q

What ADE dose Phentobarbital have? (1)

How do you monitor for this?

A

Hypotension

Monitor vital signs and ECG during administration

29
Q

What should you do if you give a patient Phentobarbital and hypotension occurs?

A

Rate of infusion should be slower or dopamine should be added

30
Q

What are the 3 ADEs of Phytoin and how do you monitor?

A
  • Hypotension and cardiac arrhythmia
  • Nystagmus

Monitor Vital signs and ECG during administration

31
Q

Which med?

  • Propylene glycol causes hypotension and cardiac arrhythmias when administered too rapidly.
  • Large loading doses are generally not given to elderly individuals with preexisting cardiac disease or in critically ill patients w/ marginal BP
A

Phenytoin

32
Q

The infusion rate of which med should be slowed if the QT interval widens or if hypotension or arrhythmias develop

A

Phenytoin

33
Q

In what medication does horizontal nystagmus suggests serum concentration above the reference range and toxicity?

A

Phenytoin

34
Q

What are the 3 ADEs of phenobarbital and how do you monitor?

A
  • ADEs: Hypotension, respiratory and CNS depression
  • Monitor vital signs and mental status. EEG if used in anesthesia doses
35
Q

Which med?

  • contains propylene glycol
  • if hypotension occurs, slow the rate of administration or begin dopamine
  • apnea and hypopnea can be more profound in patients treated initially with benzodiazepines
A

Phenobarbital

(Propylene glycol stabilizes drug but too much can cause lactic acidosis)

36
Q

What are the 3 ADEs of Propofol?

A
  • ADEs: Progressive metabolic acidosis, hemodynamic instability and bradyarrhythmias
  • Monitor: Vital signs, ECG, osmolar gap

(referred to as propofol-related infusion syndrome, which can be fatal)

37
Q

What is a side effect of Topiramate and how do you monitor?

A
  • Metabolic acidosis (extremely rare)
  • Monitor the acid base status
38
Q

What 6 tests should be ordered to evaluate for underlying cause of GCSE in children (and adults)?

A
  1. Serum glucose and a rapid “finger-stick” glucose
  2. Serum electrolytes, calcium, and magnesium levels
  3. ABGs and pH
  4. CBC
  5. Urine and blood toxicology
  6. Serum antiseizure drug levels
39
Q

What are the unique Midazolam delivery options?

A
  • Buccal
  • Intranasal
  • IV
  • IM

(swallowing not recommeded b/c not absorbed well through the stomach)

MJ- Pharm Exam 3 (17 decks)

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