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Status epilapticus

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  • 1. Status Epilepticus Dr. Ravindra K. Sharma Pediatric Specialist Fujairah Hospital, UAE drravindrakr@yahoo.co.in
  • 2. TAJ MAHAL, AGRA, INDIA
  • 3. “Status epilepticus is a medical emergency that requires an organized and skillful approach to minimize the associated mortality and morbidity”
  • 4.  Status epilepticus (SE) presents in a multitude of forms, dependent on etiology and patient age (myoclonic, tonic, subtle, tonic-clonic, absence, complex partial etc.)  Generalized, tonic-clonic SE is the most common form of SE.
  • 5. Definition:  Conventional definition:  Single  Series seizure > 30 minutes of seizures > 30 minutes without full recovery
  • 6. Definition:…. “If appropriate therapy is delayed, SE can cause permanent neurologic sequelae or death …” thus   “ … any child who presents actively convulsing should be assumed to have SE.” Haafiz A. Pediatr Emerg Care 1999;15(2):119-29
  • 7. The longer SE persists, the lower is the likelihood of spontaneous cessation the harder is it to control the higher is the risk of morbidity and mortality Treatment for most seizures needs to be instituted after > 5 minutes of seizure activity Bleck TP. Epilepsia 1999;40(1):S64-6
  • 8. But  This is not practical operational definition.  Longer periods with uncontrolled seizure activity, more likely to develop a RSE syndrome.  More practical guidelines needed to draw that arbitrary ‘line in sand’, beyond which substantial risk of developing clinical SE exists.
  • 9. Operational Definition: “Continuous seizures lasting at least 5 minutes or two or more discrete seizures between which there is an incomplete recovery of consciousness”
  • 10. Causes.        Fever Medication change Unknown Metabolic Congenital Anoxic Other (trauma, vascular, infection, tumor, drugs,endocrine) DeLorenzo RJ. Epilepsia 1992;33 Suppl 4:S15-25 36 % 20 % 9 % 8% 7 % 5 % 15 %
  • 11. Pathophysiology GLUTAMATE = the major excitatory AA neurotransmitter in brain  Any factor increases Glutamate activity can lead to seizures  NMDA(N-methyl-D-aspartic acid) is an AA derivative which acts as a specific agonist at the NMDA receptor mimicking the action of glutamate  GABA = main inhibitory neurotransmitter, ; GABA antagonists can cause SE 
  • 12. Drugs which can cause seizures   Antibiotics  Penicillins  Isoniazid  Metronidazole Anesthetics, narcotics  Halothane, enflurane  Cocaine, fentanyl  Ketamine  Psychopharmaceuticals  Antihistamines  Antidepressants  Antipsychotics  Phencyclidine  Tricyclic antidepressants  List of drugs
  • 13. Mortality   Adults Children 15 to 22% 3 to 15% Reviewed in: Fountain NB. Epilepsia 2000;41 Suppl 2:S23-30
  • 14. Prolonged seizures Temporary systemic changes Life threatening systemic changes Duration of seizure Death
  • 15. Respiratory  Hypoxia and hypercarbia - ventilation (chest rigidity from muscle spasm) Hypermetabolism ( O2 consumption, CO2 production) Poor handling of secretions - Neurogenic pulmonary edema? -
  • 16. Hypoxia   Hypoxia/anoxia markedly increase the risk of mortality in SE Seizures (without hypoxia) are much less dangerous than seizures and hypoxia Towne AR. Epilepsia 1994;35(1):27-34
  • 17. Neurogenic pulmonary edema Rare complication Likely occurs as consequence of marked increase of pulmonary vascular pressure Johnston SC. Postictal pulmonary edema requires pulmonary vascular pressure increases. Epilepsia 1996;37(5):428-32
  • 18. Acidosis   Respiratory Lactic   Impaired tissue oxygenation Increased energy expenditure
  • 19. Hemodynamics  Sympathetic overdrive  Massive catecholamine / autonomic discharge  Hypertension  Tachycardia  High CVP 0 min 60 min  Exhaustion  Hypotension  Hypoperfusion
  • 20. COMMON WEALTH GAMES, DELHI 2010.
  • 21. Cerebral blood flow - Cerebral O2 requirement  Hyperdynamic phase  O2 requirement  Exhaustion phase   Blood flow  Blood pressure Seizure duration CBF meets CMRO2 CBF drops as hypotension sets in Autoregulation exhausted Neuronal damage ensues
  • 22. Glucose Glucose  Hyperdynamic phase   SE Exhaustion phase   30 min SE + hypoxia  Seizure duration Hyperglycemia Hypoglycemia develops Hypoglycemia appears earlier in presence of hypoxia Neuronal damage ensues
  • 23. Hyperpyrexia  Hyperpyrexia may develop during protracted SE, and aggravate possible mismatch of cerebral metabolic requirement and substrate delivery  Treat hyperpyrexia aggressively  Antipyretics, external cooling
  • 24. Other alterations  Blood leukocytosis (50% of children)  Spinal fluid leukocytosis (15% of children)  K+  creatine kinase  Myoglobinuria
  • 25. Boring!
  • 26. Acute Management of Seizures 0-5 min 5-15 min 15-35 min 45 min 60 min
  • 27. Common Sense:0-5 minutes Stabilize the patient- A Oxygen, oral airway. Avoid hypoxia! B Consider bag-valve mask ventilation. Consider intubation C IV/IO access. Treat hypotension, but NOT hypertension
  • 28. (0-5 minutes)…  Arterial blood gas?  All children in SE have acidosis. It often resolves rapidly with termination of SE  Intubate?  It may be difficult to intubate the actively seizing child  Stop or slow seizures first, give O2, consider BVM ventilation  If using paralytic agent to intubate, assume that SE continues
  • 29. 0-5 minutes….  Give glucose (2-4 ml/kg D25%, infants 5 ml/kg D10%), unless normo- or hyperglycemic  Hyperglycemia has no negative effect in SE (as long as significant hyperosmolality is being avoided)  Adoloscent-Thiamin 100 mg IV first
  • 30. Initial investigations(0-5 minutes)….  Labs        Na,K, Ca, Mg, PO4 , BUN, Cret, glucose CBC Liver function tests, ammonia Anticonvulsant level Toxicology Blood C/S Initial screening history and Physical examination
  • 31. Work-Up (when stable)  Lumbar puncture   CT scan/MRI scan   Always defer LP in unstable patient, but never delay antibiotic/antiviral rx if indicated Indicated for focal seizures or deficit, history of trauma or bleeding d/o EEG
  • 32. Treatment (Pharmacotheraqpy) 5-15 minutes..  The longer we wait with anticonvulsant, the more anticonvulsant we will need to stop SE  Most common mistake is ineffective dose
  • 33. Anticonvulsants  Rapid acting plus  Long acting
  • 34. Anticonvulsants - Rapid acting  Benzodiazepines      Lorazepam 0.05- 0.1 mg/kg i.v.(rectal dose same) upto 4-6 mg over 1-2 minutes or Diazepam 0.2- 0.5 mg/kg i.v. upto 6-10mg over 1-2 minutes Diazepam 0.5 mg/kg rectally Midazolam 0.15-0.3 mg/kg IV ; nasal or Buccal (0.5 mg/kg) is used if no IV line If SE persists, repeat every 5-10 minutes
  • 35. Benzodiazepines  Lorazepam     Low lipid solubility Action delayed 2 minutes Anticonvulsant effect 6-12 hrs Less respiratory depression than diazepam Midazolam for brief seizures May be given i.m.  to treat refractory SE  Diazepam      High lipid solubility Thus very rapid onset Redistributes rapidly Thus rapid loss of anticonvulsant effect Adverse effects are persistent:   Hypotension Resp. depression
  • 36. Anticonvulsants :15-35 minutes (If seizures persists)  Phenytoin      15-20 mg/kg i.v. over 15-20 min pH 12 Extravasation causes severe tissue injury Onset 10-30 min May cause hypotension, dysrhythmia Cheap  Fosphenytoin  15-20 mg PE/kg i.v./i.m. over 57 min PE = phenytoin equivalent  Fosphenytoin 150 mg is equal to 100 mg phenytoin  pH 8.6 Extravasation well tolerated Onset 5-10 min May cause hypotension Expensive   
  • 37. Anticonvulsants :(15-35 minutes)  Phenobarbital  15-20 mg/kg (neonate 20-30 mg/kg)i.v. over 15-20 min  Onset 15-30 min  May cause hypotension, respiratory depression
  • 38. Initial choice of long acting anticonvulsants in SE Is patient an infant? Is patient already receiving phenytoin? No At high risk for extravasation ? (small vein, difficult access etc.)? No Phenytoin Yes Fosphenytoin Yes Phenobarbital
  • 39. If SE persists (45 minutes)      Phenobarbital if Phenytoin used Additional phenytoin or FP 5 mg/kg (Nelson 10 mg/kg increment) max upto 30 mg , Additional phenobarbital 5 mg/kg/dose every 15–30 min (max total dose of 30 mg/kg) be prepared to support respirations Consider IV valproate, especially for partial status epilepticus
  • 40. Seizures Persists (60 minutes)  Consider Diazepam infusion, pentobarbital (Barbiturate coma), midazolam, paraldehyde or general anesthesia infusion in PICU  Midazolam 0.2 mg/kg bolus & 20-400 mcg/kg/hr infusion  Propofol 1-2 mg/kg then 2-10 mg/kg/hr infusion  Avoid paralytics
  • 41. Still Seizures Persists….     Induction of Barbiturate coma for 48 hrs IV loading thiopental 2–4 mg/kg till a burst suppression EEG pattern till 48 hrs check phenobarbital level to be normal. Paraldehyde :loading 150–200 mg/kg IV for 15–20 min, then 20 mg/kg/hr in a 5% concentration in a glass bottle freshly prepared
  • 42. Still Seizures Persists….  General anesthesia: if barbiturate coma is not option.  halothane and Isoflurane.  Acts by reversing cerebral anoxia and metabolic abnormalities, allowing the previously administered anticonvulsants to exert their effect.
  • 43. Possible new drugs for Status      Lidocaine - some positive trials Valproate - IV form available  10-15 mg/kg IV. Gabapentin / Vigabatrin / Lamotrigine Felbamate - blocks NMDA receptors Ketamine - blocks NMDA receptors Use of AED after status episode is controversial especially idiopathic or febrile seizure.
  • 44. Non - convulsive status epilepticus?  NCSE is a term used to denote a range of conditions in which electrographic seizure activity is prolonged and results in non convulsive clinical symptoms.
  • 45. Non - convulsive SE ?  Up to 20 % of children with SE have non convulsive SE after tonic - clonic SE
  • 46. Non - convulsive SE ?  If child does not begin to respond to painful stimuli within 20 - 30 minutes after tonic clonic SE, suspect non - convulsive SE  Urgent EEG
  • 47. Summary Status Epilepticus is >5 min of seizures or two seizures without return to consciousness  Status Epilepticus is common  Delay in therapy makes SE harder to rest  Mortality and morbidity is increased in prolonged SE  BZD, Pheny/Pheno, Call for PICU  Status Epilepticus needs a DIAGNOSIS 
  • 48. Take-Home points      Better outcome if seizure stopped earlier, so no need to wait Always ABC D FIRST Lorazepam - best 1st line Rx Fosphenytoin - surpasses Phenytoin for SE, and can be given IM in difficult situation Propofol - advantages over barbiturates for resistant SE, low toxicity , quick action, and fast recovery upon discontinuation