This slides contains all you need to know about "Status Epilepticus" in a nutshell. It includes definition, investigation, emergency management of status epilepticus. This educational material is suitable for med students, paramedics, nurses & neurology residents.
This slides contains all you need to know about "Status Epilepticus" in a nutshell. It includes definition, investigation, emergency management of status epilepticus. This educational material is suitable for med students, paramedics, nurses & neurology residents.
Management of Refractory, Super refractory SE and.pptxsumeetsingh837653
diagnosis and treatment of refractory and super refractory status epilepticus and NORSE
treatment guidelines of status epilepticus
dosages of various antiepileptic used in management of status epilepticus
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Management of Refractory, Super refractory SE and.pptxsumeetsingh837653
diagnosis and treatment of refractory and super refractory status epilepticus and NORSE
treatment guidelines of status epilepticus
dosages of various antiepileptic used in management of status epilepticus
Power-sharing Class 10 is a vital aspect of democratic governance. It refers to the distribution of power among different organs of government, levels of government, and social groups. This ensures that no single entity can control all aspects of governance, promoting stability and unity in a diverse society.
For more information, visit-www.vavaclasses.com
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
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Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Solid waste management & Types of Basic civil Engineering notes by DJ Sir.pptxDenish Jangid
Solid waste management & Types of Basic civil Engineering notes by DJ Sir
Types of SWM
Liquid wastes
Gaseous wastes
Solid wastes.
CLASSIFICATION OF SOLID WASTE:
Based on their sources of origin
Based on physical nature
SYSTEMS FOR SOLID WASTE MANAGEMENT:
METHODS FOR DISPOSAL OF THE SOLID WASTE:
OPEN DUMPS:
LANDFILLS:
Sanitary landfills
COMPOSTING
Different stages of composting
VERMICOMPOSTING:
Vermicomposting process:
Encapsulation:
Incineration
MANAGEMENT OF SOLID WASTE:
Refuse
Reuse
Recycle
Reduce
FACTORS AFFECTING SOLID WASTE MANAGEMENT:
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
The Indian economy is classified into different sectors to simplify the analysis and understanding of economic activities. For Class 10, it's essential to grasp the sectors of the Indian economy, understand their characteristics, and recognize their importance. This guide will provide detailed notes on the Sectors of the Indian Economy Class 10, using specific long-tail keywords to enhance comprehension.
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2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
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This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
4. Introduction
Status Epilepticus(SE) is a common neurological
emergency with a higher rate of mortality,
neurodevelopental sequelae and morbidity.
SE may occur as a first presentation of a seizure
disorder in the life span of epilepsy or neurologically
ill patient or due to infection ,trauma , hypoxia, or
metabolic causes.
5. Definition
Definition of SE to reflect the time at which
treatment should be initiated (t1)
Time at which continous seizure activity leads to
long term sequelae such as neuronal injury (t2) .
6. Definition con’t
The 5 mins window corresponds with the time at which
urgent treatment should begin.
The classical 30 mins cut off is based on the fact that
approximately after 30 mins of generalized seizures, the
compensatory mechanisms fails against acidosis,
hyperthermia ,hyperkalemia , and cardiocirculatory
collapse .
Thus SE induced irreversible neuronal damage occures and
seizures become self-sustained and refractory to treatment.
7.
8. Definition:
Historically, status epilepticus has been conceptually
defined as “A condition characterized by an epileptic
seizure that is sufficiently prolonged or repeated at
sufficiently brief intervals so as to produce an unvarying
and enduring epileptic condition” . Roger J 1974
The International League Against Epilepsy: 30 min of
continuous seizure activity, or a series of epileptic seizures
during which function is not regained between ictal events
in a longer than 30 min period. Epilepsia. 1993
9. Epidemiology
Approximatley 17-23 of 100,000 children
experience SE every year.
From neonate to 1 year of age: 135–150 incidents
per 100,000 children
Between age 1-4 yrs (29 of 100,000) children ,
Aged 5-9 yrs (9 of 100,000) children,
And aged 10-15 yrs (2 of 100,000) children
Mortality at 3%
10. Incidence
The incidence is highest in the neonatal period
Approximately 30% of patients presenting with SE
are having their first seizure and approximately
40% of these later develop epilepsy .
11. Classification
SE may be subclassified as
o Convulsive : generalized tonic-clonic movements,
mental-status impairment, postictal focal neurologic
impairment. 90% of all SE.
o Nonconvulsive : wandering confused, mental status
impairment with or without motor movements.
o Refractory : not responsive to standard treatment. It
is defined as clinical or electrographic seizures that
continue despite adequate benzodiazepine doses and
at least one acceptable antiepileptic drug (AED).
Occurs in 30% SE.
14. Causes of SE Con’t
Known (symptomatic):
o Acute (stroke, toxicity, derangements in serum electrolytes
and blood glucose, trauma,hypoxia, febrile seizures,
neuroinfections, and inborn errors of metabolism)
o Remote (brain scars due to above causes, genetic, brain
malformations, etc.)
o Progressive (neurodegenerative disorders and tumors)
o Known cases of epilepsy: Lennox–Gastaut syndrome and
Dravet syndrome
Unknown cause: new-onset refractory status epilepticus
(NORSE), febrile infection-related epilepsy syndrome
(FIRES)
15. Mechanisms:
The establishment of sustained seizure activity seen in
SE appear to involve:
1) Failure of desensitization of AMPA (Alpha
amino -3-hydroxy-5-methyl-4-isoxazolepropionic acid)
glutamate receptors, thus causing the persistence of
increased excitability
(2) Reduction of GABA-mediated inhibition as
a result of intracellular internalization of GABA-A
receptors.
17. Pathogenesis
Failure of the normal mechanisms that terminate seizures
Reduced inhibition and persistent excessive
excitation , Ongoing seizure activity ↓GABA receptors
Pronounced excitation via glutamate analogues leads
to prolongation of seizures
18. Mechanism Con’t
During SE, there is an increased cerebral metabolic
rate and a compensatory increase in cerebral blood
flow.
When the brain is exposed to prolonged seizures ,
there is a rapid decrease in number of post synaptic
GABA-A and increase in the number of post synaptic
NMDA receptors .
This loss of inhibition and increase in excitation in the
brain synapses promote self sustaining prolonged
seizure and may explain the loss of efficacy of
benzodiazepines
20. In children with new-onset seizures, after
continuously seizing for 5–10 min, a seizure
becomes unlikely to stop without pharmacologic
intervention
Several studies have described associations
between status epilepticus management delays
and more prolonged seizures and lower anti-
seizure medication responsiveness
Thus we have to start treatment as early as possible
21. Quick History
Elicit quick history
Trauma
Antecedent illness
Fever
Ingestion
Skipped medication
22. Management con’t
Ideal drug for treating SE
Rapid entry into CNS
Rapid onset of action
Long duration of action
Safety
Absence of sedation
Useful as maintenance AED
23. Management Con’t:
Stage 1: Early phase (duration from 5 to 10 minutes)
ABCDE
Maintain Airway- patient at risk for aspiration
Breathing- place O2, be ready for intubation
Circulation- obtain IV access
Dextrose: check glucose levels
Electrolytes: check electrolytes (Na, Ca, Mg, PO4)
Check anticonvulsant levels
24. Investigations
CBC
Serum electrolytes ,ABG
Ca, Mg, PO4
Glucose
Liver function tests, S/ Creatinin
S/ Ammonia, Lactate
Anticonvulsant levels
Toxic screen
cEEG
Neuroimaging: CT Scan of Brain (use contrast if suspect brain tumor or
AVM)
25. Investigation Con’t
Lumbar puncture
Always defer LP in unstable patient, but never delay
antibiotic/antiviral rx if indicated
CT scan
Indicated for focal seizures or deficit, history of trauma
or bleeding
28. Study of out-of-hospital treatment of seizures
lorazepam vs diazepam.
Seizure activity terminated in
60% of the lorazepam-treated patients
43% of diazepam-treated patients
21% of patients who received placebo
Benzodiazepines
Alldredge B.K., Gelb A.M., Isaacs S.M., et al: A comparison of lorazepam,
diazepam, and placebo for the treatment of out-of-hospital status
epilepticus. N Engl J Med 345. (9): 631-637.2001;
Status Epilepticus Treatment
29. Diazepam
Highly lipid soluble
Rapid CNS entry- stops seizures in 1-3 minutes
Rapid redistribution in fatty tissues
Brain concentrations fall quickly
Duration of action is 15-30 minutes
T1/2= 30 hr
Dose: <3yrs, 0.5mg/kg, >3yrs, 0.3mg/kg
Side Effects: sedation, decreased respiration and
blood pressure
30. Lorazepam
Less lipid soluble than diazepam
Slower CNS, stops seizures in 6-10 min
Not as rapidly redistributed to fat stores
Longer duration of action 12-24 hr
T1/2 =14 hr
Dose: 0.05—0.1mg/kg
Side Effects: decreased LOC, respiration and BP
32. Benzodiazepines lose effectiveness in established
SE and are suboptimal for long time anti-seizure
management; therefore next line AED should be
ordered and administered early, within 10 min of
seizure onset.
33. When to start 2nd line Anticonvulsant
If seizures continue for 10 minutes after at least
two injections of a benzodiazepine, a second
therapy with a long-acting antiseizure medication
should be given ( one guideline)
Antiepileptic drugs should be administered
concurrently with benzodiazepines (one
guideline)
34. STAGE II: Established Status Epilepticus
(duration from 10 to 30 minutes)
The American Epilepsy Society’s guideline concludes that
There was insufficient evidence to evaluate phenytoin or
levetiracetam as second-line therapy (level U evidence)
I/V valproic acid has similar efficacy but better tolerability
than intravenous phenobarbital (level B evidence)
35. Comparison
Phenytoin
IV dosing 20 mg/kg load
• Onset 10-30 min
1mg/kg/min
Extravasation causes severe
tissue injury
May cause hypotension,
dysrhythmia
Precipitates with Glucose
containing fluid
Can not be given in renal
insufficiency,
hypoalbuminemia
Fosphenytoin
IV dosing 20 mg/kg load
• Onset 5-10 min
1.5mg/kg/min
Extravasation well tolerated
May cause hypotension
36. STAGE III: Refractory Status Epilepticus
(Refractory GCSE)(duration from 30 to 60
minutes)
The definition of refractory generalized CSE (GCSE) is
based on the number of anticonvulsants used
A patient is considered to have refractory SE when
Seizures continue despite first- and second-line
treatments and the seizures duration is greater than 1 hour
there is a need for general anesthesia
37. Refractory Status Epilepticus
Intubation
Continuous EEG monitoring
Drugs: Levetiracetum. Phenobarbiton, Sodium Valproate
Medication Coma
Pentobarbital
Midazolam
Propofol
Very high dose phenobarbiton
38. Treatment Stage III
Phenobarbiton
Lipid solubility < Phenytoin
Duration of action>48 hrs, T1/2= 100 hours
Dose : 15–20 mg/kg IV, may give an additional 5–10 mg/kg
Side Effects: sedation, decreased respiration and BP
39. Management of refractory status epilepticus
General anesthetics to achieve burst suppression
Midazolam—0.2 mg/kg IV bolus followed by infusion @1
μg/kg/ min, increasing 1 μg/kg/min, every 5–10 minutes,
till seizures stop, up to a maximum of 30 μg/kg/min,
tapering initiated after 24 hours of seizure control @ 1
μg/kg/min, every 3 hours
40. High-dose phenobarbitone: 5–10 mg/kg boluses every
30 minutes up to 120 mg/kg over 24 hours, target seizure
control and burst suppression, maintenance up to 40
mg/kg/day
Propofol :loading dose of 1–2 mg/kg, followed by
continuous infusion of 1–2 mg/kg/h, maximum of 5
mg/kg/h. Propofol infusion should not be used in
children due to the risk of propofol infusion
syndrome).
Thiopentone :loading dose 5 mg/kg bolus followed by 3–
5 mg/ kg/h infusion rate to achieve burst suppression
followed by tapering after 24 hours seizure free period.
41. Topiramate through orogastric/nasogastric tube (2–5
mg/kg enteral loading, increase by 5–10 mg/kg/day up to
maximum of 25 mg/kg/day) while tapering anesthetic
agents.
Ketamine can also be tried.
42. Levetiracetum
Consider Levetiracetum IV Loading
High bioavailability
Few drug interaction
Low plasma protein binding
Minimal hepatic metabolism
• Can be considered second-line
• May be preferred over benzodiazepines in specific
patients with respiratory compromise and/or
hypotension
Dose: 20-60 mg/kg
43. Valproate
Consider IV Valproic Acid
FDA approved only for replacement or oral dosing
Rapid loading dose appears safe
25-30mg/kg rapidly infused
Side Effects: dizziness, nausea
Can be initial therapy in patients with increased risk of
cardiac or respiratory abnormalities
Concern for hepatotoxicity with valproic acid use in
children younger than two years).
44. Stage IV: Super refractory status epilepticus
(duration > 24 hours)
When treatment with an IV anesthetic for more than 24 h
is not successful in controlling SE, the condition can be
termed superrefractory SE or malignant SE.
The first line therapy includes maintaining the use of
anesthetic drugs used in Phase III although other drugs
have been reported with uncertain outcomes such as
Ketamine
enteral topiramate
perampanel
bumetanide
45. Other therapeutic options included :
Hypothermia
Magnesium Infusion
Pyridoxine Infusion
Ketogenic Diet
Immunologic Therapy ( Inj Methyl Prednisolone,
IVIG)
Emergency neurosurgery including
focal resection, multiple subpial transection,
corpus callosotomy, and hemispherectomy
46. Some recommendations
When I/V access is not possible I/M fosphenytoin
( 18-20 mg/kg) can be given as a single dose
Children already getting oral phenytoin should be
cautiously given inj phenytoin @ 5 mg/kg over 5 min and
wait for blood phenytoin level
47. If the patient progresses to refractory status
epilepticus, urgent escalation of therapy should be
continued
At this point, options include administering
another bolus of the same second-line agent that
had been given or adding another agent from the
ones just discussed.
Status Epilepticus in Adults: A Review of Diagnosis
and Treatment.2016
48. Supportive Therapy
Glucose Infusion: 10% dextrose 2ml/kg
Hyperglycemia has no negative effect in SE
(as long as significant hyperosmolality is being
avoided)
49. Supportive Therapy
Inj Mannitol 5ml/kg over 10 min if seizure
continues for 30 min to decrease cerebral oedema
In any step if seizure is controlled, start on
maintenance therapy- after 12hours of bolus dose
Maintenance dose of Phenobarbintone – 2.5-4
mg/kg/dose 12 hourly and in case of Fosphenytoin
it is 7.5mg/kg/dose 12 hourly.
50. Tapering
In Pt having continuous infusion of an AED- after
cessation of seizure, the infusion should be
continued for 12-24 hours. Then gradual tapering
is advised over 24 hour
51.
52.
53.
54.
55.
56.
57.
58.
59. Outcome and prognosis
Factors that determine outcome include
Age of the child
Rapidity of seizure control
Adequacy of care
Time from seizure onset to initiation of treatment
is inversely corelated with the % of patient who
responded to 1st line AEDs.
-at 30 mins 80% responded
-at 90 mins 44%
Periodic lateralized epileptiform discharges at any
time of SE , associated with poor outcome.
61. Take Home Message
Status epilepticus is a medical emergency
Better outcome if seizure stopped earlier
Early treatment and stepwise treatment is the
most important prognostic factors
Consideration of NCSE should be kept in mind
Targeted investigations should be done
Supportive management is very important
Planning should be done to prevent further attacks