Download Status epilepticus

Status epilepticus
Status Epilepticus
 Traditionally, SE is defined as continuous or
repetitive seizure activity persisting for at
least 30 minutes without recovery of
consciousness between attacks.
 For all practical purposes, a patient should
be considered to be in SE if a seizure
persists for more than 5 minutes.
Status Epilepticus
classification
Generalized
convulsive status
epilepticus
Non convulsive
status
epilepticus
Focal motor
status
epilepticus
Epidemiology and Risk Factor
 100,000 to 150,000 patients per year in the
United States are diagnosed with SE.
 Approximately one half of the cases occur in
young children, but the risk in adults older
than 60 years of age is high.
 The published incidence of SE usually under
estimate NCSE.
Status epilepticus occurs in :
1
2
3
• in patients who sustain an acute process that affects the brain,
such as metabolic disturbances, hypoxia, CNS infection, head
trauma, or drug intoxication
• in patients with epilepsy experiencing an exacerbation of seizures,
often as a result of abrupt reduction in antiepileptic medication;
• as a first unprovoked seizure, often heralding the onset of epilepsy.
Etiology of status epilepticus in adult
Status epilepticus in pediatrics
 Convulsive status epilepticus is the most
common neurological emergency in
childhood.
 Prolonged febrile sizeurs is the most
common cause.
 Low morbidity and mortality .
 The general principle of management is the
same as adult.
Causes of first episode of convulsive status epilepticus in
children
Management of SE
 Rapidity of treatment is important.
 Therapeutic intervention are most effective
when started early and efficacy decrease
significantly with increasing seizures
duration.
 Initial step include basic life support ,
focused history , initiating IV access ,
laboratory studies and benzodiazepine.
BLS
history
Benzodia
zepine
• Give oxygen. Stabilize airway , breathing and circulation.
• IV access and ECG monitoring.
• Prior history of epilepsy , alcohol or drug use or acute
neurological insult.
• Description of seizure onset from a witness.
• IV lorazepam 4mg over 2 min.
• Rectal , nasal or buccal benzodiazpine should be given if any
delay will occur in obtaining IV accsee.
Lab
Persistent
Seizures
ICU
• U&E , Mg , Ca , Phos , CBC , LFT , AED level , ABG ,
trpnonin, toxicology screen ( urine & blood) , glucose.
• Phenytoin 15 mg /kg at 50 mg /min or fosphenytoin.
• BP and ECG monitoring.
• If sizeurs persist following option can de done under
intensive care monitoring:
midazolam
• Load with 0.2mg/kg repeat boluses every 5 min. until seizures stop.
• CIV 0.1mg/kg/hour max rate is 2.9 mg /kg/hr.
• If still having seizurs add or swith to propofol or pentobarbital.
Propofol
• Load 1mg/kg reboluse every 3 min. max total dose is 10mg/kg.
• CIV 1 to 15 mg/kg /hr.
• If still having seizeurs add or swith to midazolam or pentobarbital.
Valporate
• 40mg/kg over 10 min if still seizing add 20mg/kg.
• If still having seizeurs
Phenobarbital
• 20mg/kg IV at 50mg/min.
• If still having seizurs shift to CIV
midazolam ,propofol or
pentobarbital
If sizeurs presist more than 60 min
Refractory status epilepticus
 CIV pentobarbital. Load: 5 mg/kg at up to 50
mg/min; repeat 5 mg/kg boluses until seizures
stop. Initial CIV rate: 1 mg/kg/h. CIV dose
range: 0.5 mg/kg/h to 10 mg/kg/h.
 traditionally titrated to suppression burst on EEG
but titrating to seizure suppression is reasonable
as well.
Parmacotheray for treatment of status
Epilepticus
Parmacotheray for treatment of status
Epilepticus
Parmacotheray for treatment of status
Epilepticus
Parmacotheray for treatment of status
Epilepticus
Parmacotheray for treatment of status
Epilepticus
Parmacotheray for treatment of status
Epilepticus
Parmacotheray for treatment of status
Epilepticus
EEG monitoring
 EEG is mandatory for correct diagnosis and monitoring
response to therapy.
 Residual electrical seizure activity occur almost in 50% of
patient who present with GCSE after cessation of motor
activity.
 Persistent NCSE can prevent recovery and add to morbidty.
Complication of SE
 Hippocampal complex ,
amygedla , thalmus are
vulnerable to SE which
lead to permanent
impairment in memory ,
affect and cognetion.
 Mortality range between
3% to 20% , children have
lower mortality rate than
adult.
Future Directions
 IV lorezpam is an excellent first line treatment
but step after that are less clear and require and
require randomized trials.
 Neuroprotection is a new focus for research ,
some newer AEDs have neuroprotictive property
that may prevent neuronal injury ,other
neuroprotictive methods are hypothetmia ,
antioxidants and erythropoietin.
Future Directions
 Development of reliable neuronal injury marker
will be quite helpful in determining which
patient require aggressive treatment and to
predict outcome.
 Neuron specific enolase which is elevated in
patient with SE and correlate with duration and
outcome is under investigation to be used as a
marker.
Thank you
Hind Alnajashi