STATUS EPILEPTICUS Department of Neurology Yashoda Hospital, Secunderabad.
STATUS EPILEPTICUS <ul><li>Definition </li></ul><ul><ul><li>Continuous seizures or repetitive, discrete seizures with impa...
Etiology  <ul><li>Drug change/noncompliance </li></ul><ul><li>Stroke </li></ul><ul><li>CNS infection </li></ul><ul><li>Alc...
Continued… <ul><li>Metabolic </li></ul><ul><li>Intra-cranial space occupying lesion </li></ul><ul><li>Trauma </li></ul><ul...
Classification  <ul><li>Convulsive status </li></ul><ul><ul><li>Primary generalized </li></ul></ul><ul><ul><li>Secondary g...
CONVULSIVE STATUS EPILEPTICUS   <ul><li>Generalised tonic clonic convulsion </li></ul><ul><li>Consequences  </li></ul><ul>...
Early Consequences <ul><li>Heart rate & Blood pressure </li></ul><ul><li>Blood Glucose </li></ul><ul><li>Cardiac Arrhythmi...
Late Consequences <ul><li>Fall in BP </li></ul><ul><li>Loss of cerebral auto-regulation  </li></ul><ul><li>Hypoglycemia du...
Management  <ul><li>First stage (0-10min) </li></ul><ul><li>Oxygen and Cardio respiratory Resuscitation  </li></ul><ul><li...
Second Stage(1-60min) <ul><li>Monitoring  </li></ul><ul><li>- Regular Neurological Observation </li></ul><ul><li>-Pulse, B...
Continued… <ul><li>Emergency Investigations-  </li></ul><ul><li>-Sugar,ABG Renal and liver Function Test </li></ul><ul><li...
Third Stage(0-60/90min) <ul><li>Establish etiology: - </li></ul><ul><li>-Age, History  </li></ul><ul><li>-Investigations <...
Fourth Stage <ul><li>ICU monitoring </li></ul><ul><li>-ECG, Pulseoxymetry  </li></ul><ul><li>Seizure and EEG monitoring </...
Anti-convulsant drug Therapy <ul><li>Stage of Early Status </li></ul><ul><li>-Lorazepam: -4 mg IV Bolus (0.07mg/kg) </li><...
Continued… <ul><li>Seizures continuing / Stage of Established Seizure   </li></ul><ul><li>Phenytoin :-   15-20mg/kg Bolus ...
<ul><li>Seizures continuing / Stage of Refractory Status </li></ul><ul><li>- general anesthesia should be induced </li></u...
Non-Convulsive Status Epilepticus <ul><li>Continuous Neuronal Discharge but no Convulsions </li></ul><ul><li>Diagnosis dep...
Treatment  IV Phenytoin (fosphenytoin)or phenobarbital Non-convulsive status epilepticus in coma Oral valproate  Atypical ...
Epilepsia Partialis Continua <ul><li>Regular or irregular clonic muscular twitching, affecting limited part of body, occur...
Myoclonic Status Epilepticus in coma <ul><li>Well recognized complication of cardiorespiratory arrest (Hypoxia) </li></ul>...
STATUS EPILEPTICUS -action plan <ul><li>Drugs- </li></ul><ul><li>Initiate with  lorazepam  or  midazolam </li></ul><ul><li...
Other drugs in Status epilepticus <ul><li>Valproate </li></ul><ul><li>IV bolus  15-30 mg/kg </li></ul><ul><li>Magsulf </li...
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Status epilepticus ninad

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Status epilepticus ninad

  1. 1. STATUS EPILEPTICUS Department of Neurology Yashoda Hospital, Secunderabad.
  2. 2. STATUS EPILEPTICUS <ul><li>Definition </li></ul><ul><ul><li>Continuous seizures or repetitive, discrete seizures with impaired consciousness in the inter-ictal period. Duration of seizure activity should be 15-30 min. OR </li></ul></ul><ul><ul><li>Single seizure lasting for >10min. OR </li></ul></ul><ul><ul><li>More than 3 seizures within 30 min. </li></ul></ul>
  3. 3. Etiology <ul><li>Drug change/noncompliance </li></ul><ul><li>Stroke </li></ul><ul><li>CNS infection </li></ul><ul><li>Alcohol </li></ul><ul><li>Hypoxia </li></ul>
  4. 4. Continued… <ul><li>Metabolic </li></ul><ul><li>Intra-cranial space occupying lesion </li></ul><ul><li>Trauma </li></ul><ul><li>Fever/infection </li></ul><ul><li>Congenital </li></ul>
  5. 5. Classification <ul><li>Convulsive status </li></ul><ul><ul><li>Primary generalized </li></ul></ul><ul><ul><li>Secondary generalized </li></ul></ul><ul><li>Non convulsive status </li></ul><ul><li>Epilepsia Partialis Continua </li></ul><ul><li>Myoclonic Status Epilepticus </li></ul>
  6. 6. CONVULSIVE STATUS EPILEPTICUS <ul><li>Generalised tonic clonic convulsion </li></ul><ul><li>Consequences </li></ul><ul><li>-Early: - Because of release of </li></ul><ul><li>Catechloamines </li></ul><ul><li>-Late: - Failure of Cerebral and systemic </li></ul><ul><li>protective measures </li></ul>
  7. 7. Early Consequences <ul><li>Heart rate & Blood pressure </li></ul><ul><li>Blood Glucose </li></ul><ul><li>Cardiac Arrhythmias </li></ul><ul><li>Gradual rise in Temperature (Prolonged Hyperthermia) </li></ul><ul><li>Acidosis ( Lactic acid production) </li></ul>
  8. 8. Late Consequences <ul><li>Fall in BP </li></ul><ul><li>Loss of cerebral auto-regulation </li></ul><ul><li>Hypoglycemia due to exhaustion of glycogen stores & Neurogenic insulin secretion </li></ul><ul><li>Cerebral Oedema </li></ul><ul><li>Rhabdomyolysis leading to ATN, Hyperkalemia and hyponatraemia </li></ul><ul><li>Rarely DIC </li></ul>
  9. 9. Management <ul><li>First stage (0-10min) </li></ul><ul><li>Oxygen and Cardio respiratory Resuscitation </li></ul><ul><li>-Cardio respiratory assessment </li></ul><ul><li>- Secure airway </li></ul><ul><li>-Resuscitate if require </li></ul><ul><li>-Oxygen should always be administered </li></ul>
  10. 10. Second Stage(1-60min) <ul><li>Monitoring </li></ul><ul><li>- Regular Neurological Observation </li></ul><ul><li>-Pulse, BP, ECG </li></ul><ul><li>IV lines </li></ul><ul><li>-Normal saline </li></ul><ul><li>-separate lines for different drugs. </li></ul><ul><li>-Drugs should not be mixed </li></ul><ul><li>Emergency Anti-convulsant Therapy </li></ul>
  11. 11. Continued… <ul><li>Emergency Investigations- </li></ul><ul><li>-Sugar,ABG Renal and liver Function Test </li></ul><ul><li>-Calcium, Magnesium Level, CBP </li></ul><ul><li>-Anticonvulsant level </li></ul><ul><li>IV glucose & thiamine </li></ul><ul><li>-50ml of 50% dextrose should be given I.V. if hypoglycemia is suspected. </li></ul><ul><li>-If there is h/o alcoholism 250mg of Thiamine should be given I.V. </li></ul>
  12. 12. Third Stage(0-60/90min) <ul><li>Establish etiology: - </li></ul><ul><li>-Age, History </li></ul><ul><li>-Investigations </li></ul><ul><li>-CT/MRI Brain, CSF examination </li></ul><ul><li>Medical complications - Hypoxia, Hypo- & Hyper-tension, Cardiac arrhythmias, Cardiac failure, lactic acidosis, Hyperpyrexia, Hypoglycemia , Electrolyte disturbance, raised ICP, organ failure, Rhabdomyolysis, DIC </li></ul>
  13. 13. Fourth Stage <ul><li>ICU monitoring </li></ul><ul><li>-ECG, Pulseoxymetry </li></ul><ul><li>Seizure and EEG monitoring </li></ul><ul><li>-Prolonged Status Epilepticus </li></ul><ul><li>-Comatose Ventilated Patients </li></ul><ul><li>Initiate long term anticonvulsant therapy </li></ul><ul><li>-Start long Term AEP </li></ul>
  14. 14. Anti-convulsant drug Therapy <ul><li>Stage of Early Status </li></ul><ul><li>-Lorazepam: -4 mg IV Bolus (0.07mg/kg) </li></ul><ul><li>Can be repeat after 10 min. </li></ul><ul><li>-Midazolam: -0.1 – 0.3 mg/kg IV bolus –at 4 mg/min </li></ul><ul><li>Adverse effects : </li></ul><ul><ul><ul><ul><ul><li>respiratory depression </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul></ul></ul>
  15. 15. Continued… <ul><li>Seizures continuing / Stage of Established Seizure </li></ul><ul><li>Phenytoin :- 15-20mg/kg Bolus dose IV at the </li></ul><ul><li>rate of 50mg/min . </li></ul><ul><li>Fosphenytoin :- 15-20mg PE/kg Bolus dose IV </li></ul><ul><li>at the rate of 150mg/min </li></ul><ul><li>(Repeat dose of 5-10mg/kg can be given) </li></ul><ul><li>Phenobarbital :-10mg/kg Bolus IV at the rate of </li></ul><ul><li>100mg/min. </li></ul>
  16. 16. <ul><li>Seizures continuing / Stage of Refractory Status </li></ul><ul><li>- general anesthesia should be induced </li></ul><ul><li>Propofol :- 2mg/kg IV bolus,Repeat if necessary, followed by infusion (5mg/kg/hr) </li></ul><ul><li>Thiopental :- 100-250mg IV bolus over 20 sec. with further 50mg bolus every 2-3 min.until seizure control followed by IV infusion(3-5mg/kg/hr) </li></ul><ul><li>Midazolam :- 0.1-0.3mg/kg IV bolus dose at the rate of 4mg/min followed by infusion(0.05-0.4mg/kg/hr) </li></ul><ul><li>If seizures have been controlled for 12hrs., reduce the dose over further 12hrs. </li></ul><ul><li>If seizure recurs again GA agent should be given </li></ul>
  17. 17. Non-Convulsive Status Epilepticus <ul><li>Continuous Neuronal Discharge but no Convulsions </li></ul><ul><li>Diagnosis dependant on EEG </li></ul><ul><li>Presentation:-known epilepsy patient </li></ul><ul><li>-Prolonged change in personality </li></ul><ul><li>-Prolonged Post ictal stage ( >30min) </li></ul><ul><li>-Recent onset of Psychosis </li></ul>
  18. 18. Treatment IV Phenytoin (fosphenytoin)or phenobarbital Non-convulsive status epilepticus in coma Oral valproate Atypical absence status epilepticus Oral clobazam Complex partial status epilepticus IV or oral benzodiazepines Typical absence status epilepticus Treatment Type
  19. 19. Epilepsia Partialis Continua <ul><li>Regular or irregular clonic muscular twitching, affecting limited part of body, occuring for minimum of 1hr, at interval of not more than 10s </li></ul><ul><li>Causes :- Stroke, Trauma, cerebral inf./abscess, hyperglycemia, hyponatraemia </li></ul><ul><li>EEG :-Focal abnormality / may be Normal </li></ul><ul><li>Treatment :- Treat underlying cause.Antiepileptic drug can be considered to prevent complex partial or secondary generalize seizures. </li></ul>
  20. 20. Myoclonic Status Epilepticus in coma <ul><li>Well recognized complication of cardiorespiratory arrest (Hypoxia) </li></ul><ul><li>Characterized by spontaneous and stimulus sensitive myoclonus occurs within 24hrs of coma. </li></ul><ul><li>Treatment:-Clonazepam, valproate, piracetam </li></ul><ul><li>Prognosis:- Usually Poor </li></ul>
  21. 21. STATUS EPILEPTICUS -action plan <ul><li>Drugs- </li></ul><ul><li>Initiate with lorazepam or midazolam </li></ul><ul><li>Maintain with phenytoin / fosphenytoin </li></ul><ul><li>If status persists- phenobarbital </li></ul><ul><li>If status persists- pentobarbital or propofol,thiopental anaesthesia with ventilatory support </li></ul>
  22. 22. Other drugs in Status epilepticus <ul><li>Valproate </li></ul><ul><li>IV bolus 15-30 mg/kg </li></ul><ul><li>Magsulf </li></ul><ul><li>Indication – Refractory status </li></ul><ul><li>Dose:-4 gm IV bolus followed by 5 gm deep IM on both sides. rpt. 4hrly </li></ul><ul><li>Clonazapeam </li></ul><ul><li>Indication – Early status (Alternative to lorazepam) </li></ul><ul><li>Dose 1-2 mg bolus over 30 sec. </li></ul>
  23. 23. Thank you
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