- Status epilepticus has a worldwide incidence of 3.8 to 38 per 100,000 people per year, with peaks in children and the elderly. Around 31-44% of cases are refractory to initial treatment.
- Initial treatment involves benzodiazepines like lorazepam or diazepam. If seizures continue, second-line drugs like phenytoin, fosphenytoin, or valproate are used.
- Refractory status epilepticus is defined as failure to control seizures with benzodiazepines and other antiepileptics. It requires general anesthesia with drugs like propofol, thiopental, or midazolam along with
Status epilepticus (SE) is a medical emergency that starts when a seizure hits the 5-minute mark (or if there’s more than one seizure within 5 minutes).
Convulsive Status epilepticus-
The convulsive type is more common and more dangerous.
It involves tonic- clonic seizures (grand mal seizures)
In the tonic phase ( lasts less than 1 minute), body becomes stiff and person lose consciousness. Eyes roll back into head, muscles contract, back arches, and trouble breathing.
As the clonic phase starts, body spasms and jerks occur. Neck and limbs flex and relax rapidly but slow down over a few minutes.
Once the clonic phase ends, patient might stay unconscious for a few more minutes. This is the postictal period.Non-convulsive Status epilepticus-
Patient lose consciousness but is in an “epileptic twilight” state.
There might not able any shaking or seizing at all, so it can be very hard for someone observing patient to figure out what’s happening.
A non-convulsive seizure can turn into a convulsive episode.
Poorly controlled epilepsy
Low blood sugar
Stroke
Kidney failure
Liver failure
Encephalitis
HIV
Alcohol or drug abuse
Genetic diseases such as Fragile X syndrome and Angelman syndrome
Head injuries
Intracerebral hemorhage Diagnosis and managementRamesh Babu
About ICH - Diagnosis and management, Discussed the clinical presentation, evaluation, radiological features and management including recent guidelines
Presentation given by Dr Catherine Poots from Craigavon Area Hospital at the 2014 Northern Ireland Intensive Care Society annual Coppel Prize on Wednesday November 26th
Status epilepticus (SE) is a medical emergency that starts when a seizure hits the 5-minute mark (or if there’s more than one seizure within 5 minutes).
Convulsive Status epilepticus-
The convulsive type is more common and more dangerous.
It involves tonic- clonic seizures (grand mal seizures)
In the tonic phase ( lasts less than 1 minute), body becomes stiff and person lose consciousness. Eyes roll back into head, muscles contract, back arches, and trouble breathing.
As the clonic phase starts, body spasms and jerks occur. Neck and limbs flex and relax rapidly but slow down over a few minutes.
Once the clonic phase ends, patient might stay unconscious for a few more minutes. This is the postictal period.Non-convulsive Status epilepticus-
Patient lose consciousness but is in an “epileptic twilight” state.
There might not able any shaking or seizing at all, so it can be very hard for someone observing patient to figure out what’s happening.
A non-convulsive seizure can turn into a convulsive episode.
Poorly controlled epilepsy
Low blood sugar
Stroke
Kidney failure
Liver failure
Encephalitis
HIV
Alcohol or drug abuse
Genetic diseases such as Fragile X syndrome and Angelman syndrome
Head injuries
Intracerebral hemorhage Diagnosis and managementRamesh Babu
About ICH - Diagnosis and management, Discussed the clinical presentation, evaluation, radiological features and management including recent guidelines
Presentation given by Dr Catherine Poots from Craigavon Area Hospital at the 2014 Northern Ireland Intensive Care Society annual Coppel Prize on Wednesday November 26th
status epilepticus is medical emergency ,it can be convulsive or non convulsive
febrile convulsions are the most common provoked seizures in children of age 6 to 60 months
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
Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. I'm barely responsible for compilation of various resources per my interest. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.
CONCEPT OF NODOPATHIES AND PARANODOPATHIES.pptxNeurologyKota
emergence of autoimmune neuropathies and role of nodal and paranodal regions in their pathophysiology.
Peripheral neuropathies are traditionally categorized into demyelinating or axonal.
dysfunction at nodal/paranodal region key for better understanding of patients with immune mediated neuropathies.
antibodies targeting node and paranode of myelinated nerves have been increasingly detected in patients with immune mediated neuropathies.
have clinical phenotype similar common inflammatory neuropathies like Guillain Barre syndrome and chronic inflammatory demyelinating polyradiculoneuropathy
they respond poorly to conventional first line immunotherapies like IVIG
This presentation briefs out the approach of dementia assessment in line with consideration of recent advances. Now the pattern of assessment has evolved towards examining each individual domain rather than lobar assessment.
This presentation contains information about Dementia in Young onset. Also it describes the etiologies, clinical feature of common YOD & their management.
Entrapment Syndromes of Lower Limb.pptxNeurologyKota
This presentation contains information about the various Entrapment syndromes of Lower limb in descending order of topography. It also contains information about etiology, clinical features and management of each of these entrapment syndromes with special emphasis on electrodiagnostic confirmation.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
2. • Worldwide incidence of Convulsive Status Epilepticus
- 3.8 to 38 per lakh per year in children.
- 6 to 27 per lakh per year in adults.
• Bimodal peak distribution, with peaks in children and
elderly.
• Frequency of refractory status epilepticus in status
epilepticus patients = 31-44%
• No community based incidence studies in India but is
expected to be high because of high prevalence of
epilepsy, CNS infections and treatment gap.
J K Murthy Convulsive status epilepticus API India 2013
3. • In approximately 50% cases, there is no prior
history of epilepsy.
• Males are affected more compared to females
partly attributed to lower seizure threshold in
males.
• Mortality rates range between 10.5-28%.
• Neurological or cognitive sequelae in convulsive
SE occur in 11- 16 % patients.
4. • Factors associated with poor outcome after
generalised SE :
– Underlying etiology
– De novo development in hospitalised patients
– Older age
– Associated medical complication
– Duration of seizures
– Focal neurological signs at onset
6. • According to an Indian study, the etiology of Status Epilepticus
was Infection in 53.8%, drug default in 7.9%, metabolic in
14.5%, Stroke in 12.8% and miscellaneous in 11% of patients.
• Infection as an etiology was more common in children, drug
default and metabolic causes in adult and stroke in elderly.
• Mortality = 29% (elderly >> children)
(A clinical, radiological and outcome study of status
epilepticus, India J Neurology (2010) 257:224-229)
7. Definition
• The first definition of Status Epilepticus came from
Clark and Prout as “ maximal development of
epilepsy in which seizures are so frequent that coma
and exhaustion are continuous between seizures.”
• The first official definition of SE was the product of
10th Marseilles Colloquium (1962) which was
accepted by International League Against Epilepsy
(ILAE) in 1964 and modified in 1971 as “a seizure
that persists for sufficient length of time or repeated
frequently enough that recovery between attacks
does not occur.”
8. Operational Definition
• Status Epilepticus is defined as 5 minutes or
more of :
1.continuous clinical and/or electrographic
seizure activity or
2. recurrent seizure activity without
recovery (returning to baseline) between
seizures
9. Clinical features
• Genaralized convulsive status epileptics-
• Self-perpetuating generalized tonic-clonic seizure or of
a series of generalized tonic-clonic seizures without
return to consciousness in between seizures.
• Initial compensatory phase-sympathetic overdrive
a. increased C.O.
b. increased BP
c. increased BS
d. increased blood lactate levels
11. • Nonconvulsive status epilepticus
• Diverse - severe impairment of consciousness to
subtle phenomena.
• Motor manifestations if any –needs careful CNS
exam.
• Often mistaken for psychiatric disorders.
12. • Refractory status epilepticus
• Do not repond to standard treatment regimen
for status epilepticus (adequate doses of intial
BZD followed by a second acceptable
antiepileptic drug )
• Nearly 40% of status epilepticus are refractory.
• Predictors- encephalitis / nonstructural
causes(HIE) / delayed diagnosis & treatment .
13. • Malignant / Super- refractory status
epilepticus
• Status epilepticus that does not respond to a
course of anesthetic drug.
• 20% of refractory status epilepticus patients.
• Needs combination therapy (AED & Anesthetic
drugs) .
15. Aims of management of Status Epilepticus are as
follows :-
1. Termination of Status Epilepticus
2. Prevention of Seizure Recurrence
3. Management of Precipitating cause
4. Management of complications
16. Approach: Diagnostic workup
All patients
• Obtain IV access
• Monitor vital signs (ABC).
• Head CT (appropriate for most cases)
• Labs: blood glucose, CBC, renal function tests, Calcium,
Magnesium, electrolytes, AED levels.
• cEEG monitoring (preferably)
Consider based on clinical presentation
• Brain MRI
• Lumbar puncture
• Toxicology panel (i.e. isoniazid, TCAs, theophylline, cocaine,
sympathomimetics, organophosphates, cyclosporine)
• Other relevant investigations as per the need
Brophy, et al NCC 2012
17. Continuous EEG Monitoring
Brophy, et al NCC 2012
•The use of cEEG is usually required for the treatment of SE.
•Continuous EEG monitoring should be initiated within 1 h of SE
onset if ongoing seizures are suspected.
•The duration of cEEG monitoring should be at least 48 h in
comatose patients to evaluate for non-convulsive seizures.
18. Indications for cEEG in SE
Brophy, et al NCC 2012
• Recent clinical seizure or SE without return to
baseline >10 min
• Coma, including post-cardiac arrest
• Epileptiform activity or periodic discharges on initial
30 min EEG
• Suspected non-convulsive seizures in patients with
altered mental status
19. Continuous EEG treatment endpoints
Brophy, et al NeuroCritical Care 2012
• Cessation of non-convulsive seizures
• Diffuse beta activity
• Burst suppression 8–20 s intervals
• Complete suppression of EEG
21. BENZODIAZEPINES
• Drug of choice for out of hospital as well as in-
hospital treatment.
• Effective in terminating seizures in 59-78 % cases.
• Lorazepam is the DOC for IV administration.
• Midazolam is the DOC for IM administration.
• Rectal Diazepam is effective in children.
• Other routes are buccal Midazolam and intranasal
Midazolam (not commonly used)
22. • Benzodiazepines
– Diazepam
- 10mg IV push over 30-60 seconds
- repeat after 10-15mins, upto 40mg (5mg/min)
-Repeat after 2-4hrs. (max 100mg/day)
- bolus dose should be given in undiluted form
at rate not exceeding 2-5 mg/min.
– Lorazepam
0.1- 0.15 mg/kg i.v, upto 4-6 mg over 1-2 minutes
If SE persists, repeat every 5-10 minutes
23. • Diazepam
One of the drug of choice for first line management of SE
• Good results, easy to administer. (fast acting, short lasting)
• More lipid soluble, hence short distribution half-life.
• Anti-seizure effect 15-30min.
• Sufficient cerebral levels are achieved within 1 min of IV
administration and about 20 mins after rectal
administration.
• Elimination half life abt 24 hrs (may accumulate)
• Side effects -- hypotension, bradycardia,
respiratory depression, cardiac arrest,
tolerance, depresses mental status.
• In children and elderly :
Rectal Diazepam 0.5 mg / kg in children and 10 mg
in elderly are also good alternatives.
24. • Lorazepam
• Has emerged as preferred BZD for treatment of SE
• The veteran affairs (VA) co-operative study demonstrated
advantage of IV Lorazepam over Phenytoin.
• Less lipid distribution with distribution half life of 2-3
hours
• So Fast acting, longer lasting compared to Diazepam
– Longer therapeutic half-life. Anti-seizure effect for
6-12hrs.
– 2mg dose, upto a max dose of 8mg in total
• Main disadvantage is rapid devlopment of tolerance,
hence repeated doses are less effective and has no role
in long term therapy.
25. • - If Benzodiazepines are successful in stopping
• GCSE, the decision to add another agent
• depends on the underlying etiology.
• - If the etiology is reversible (e.g. metabolic or
• toxic factors), BZDs may be the only treatment
• necessary.
• - Another longer-acting AED is needed if the
• underlying etiology is not rapidly reversible.
26. Seizures continuing / Stage of Established Seizure
• In patients taking Sodium Valproate -25mg/kg iv
sodium valproate can be tried who may be sub
therapeutic.
• Phenytoin:- 20mg/kg Bolus dose IV at the rate of
50mg/min.
• Fosphenytoin:- 20mg PE/kg Bolus dose IV at the rate
of 150mg/min
• Above drugs have advantage that they lack sedative
effects.
27. Phenytoin Fosphenytoin
• 15-20 mg/kg i.v.
@50mg/min
• 100 mg phenytoin =
• 20 mg PE/kg i.v @
150mg/min
Fosphenytoin 150 mg
pH 12
Extravasation causes
severe tissue injury
pH 8.6
Extravasation well
tolerated
• Onset 10-30 min • Onset 5-10 min
•May cause hypotension,
dysrhythmia
(may be because of rapid administration
and propylene glycol which is used as
diluent)
• less cardiac complications as it
is water soluble and propylene
glycol is not used as diluent.
• Cheap • Expensive
28. Fosphenytoin Vs. Phenytoin
• SO Fosphenytoin injection has the following advantages over
phenytoin
100% bioavailability
better tolerated at site of injection.
can be given IV more rapidly .
can be given IM when cardiac monitoring is not necessary
• But has the following disadvantages
– conversion of fosphenytoin to phenytoin takes about 15
minutes. Hence inappropriate for the initial treatment of
status epilepticus (SE).
– transient paraesthesia and pruritus occur more frequently
than with phenytoin.
– the use of phenytoin equivalents may be confusing.
29. PHENOBARBITAL
• Used in SE when BZD and Phenytoin have
failed.
• Loading dose – 15-20 mg/kg
• Causes sedation and hypotension, so airway
protection should be done.
• Diluted in Polyethylene Glycol which results in
complications like renal failure, myocardial
depresion and seizures.
30. SODIUM VALPROATE
• FDA approved use in SE in 1997
• Parenteral loading is done when oral therapy is not
possible.
• Broadspectrum action and is also useful in absence and
myoclonic SE.
• Patients not responding to 2 first line AEDs may be given
parenteral sodium valproate, especially in setting where
intubation and artificial ventilation are not feasible.
31. PARALDEHYDE
• Is used as an alternative to Diazepam in early SE where IV
administration is difficult or conventional AED are
contraindicated or preoved ineffective.
• Given rectally or I/M with fast and complete absorption with
rapid onset of action.
• Seizure tend to recur after initial control.
• Inappropriately diluted or decomposd drug is highly toxic.
• Given at a dose of 10-20ml of 50% solution rectally or I/M.
• Diluted in NS or arachis oil for rectal or I/M route.
• For I/V route, given as a 5 % infusion in 5% dextrose, freshly
prepared up every 3 hours.
32. Refractory Status Epilepticus
Brophy, et al NCC 2012
•Refractory SE therapy recommendations should consist of
continuous infusion AEDs, but vary by the patient’s underlying
condition
•Dosing of continuous infusion AEDs for RSE should be titrated
to cessation of electrographic seizures or burst suppression
•During the transition from continuous infusion AEDs in RSE, it
is suggested to use maintenance AEDs and monitor for
recurrent seizures by cEEG during the titration period.
•A period of 24–48 h of electrographic control is recommended
prior to slow withdrawal of continuous infusion AEDs for RSE
33. Seizures continuing / Stage of Refractory Status
-General anesthesia should be induced
Propofol:- 2mg/kg IV bolus,Repeat if necessary, followed by
infusion (2 – 10 mg/kg/hr)
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)
Midazolam:- 0.3mg/kg IV bolus dose at the rate of 4mg/min,
rpt every 5 min 3 doses followed by infusion(2 ug/kg/hr)
Neuromuscular Blocking Agents :
If seizures have been controlled for 12hrs., reduce the
dose over further 12hrs.
If seizure recurs again GA agent should be given
34. Lowenstein DH, Status Epilepticus, NEJM (1998)
• No difference has been found in mortality in groups
treated with either of these agents.
• Pentobarbital was associated with lower frequency
of acute treatment failures and breakthrough
seizures.
• Superior pharmacokinetics and adverse effects
profile makes Propofol preferred drug in Refractory
status epilepticus in children as well as adults
35. THIOPENTONE
• Barbiturate anaesthetic given in ICU setting as patient
requires intubation and mechanical ventialtion.
• Most troublesome S/E- hypotension (may require pressor
therapy)
• Tendency to accumulate
• Caution advised in elderly or in cardiac, hepatic or renal
diseases.
• 100-250mg bolus over 20 secs, with further 50mg
boluses every 2-3 mins till seizures are controlled with
maintainence dose as 3-5mg/kg/hr.
• Aqueous solution is unstable if exposed to air.
36. PROPOFOL
• Nonbarbiturate anesthetic
• Highly lipid soluble with high volume of
distribution resulting in rapid and short lived
action.
• Causes profound respiratory and cerebral
depression requiring assisted ventilation.
• May cause involuntary movements which are not
to be confused with seizures
• 2 mg/kg bolus dose followed by 5-10 mg/kg/hr
infusion.
37. LEVITIRACETAM
• S-enantiomer of Piracetam
• Was introduced for treatment of SE in 2006
• Insufficient data on safety and efficacy of this
drug in status epilepticus.
• Several case reports its use in SE.
• European federation of neurological societies
proposes its usefulness in refractory complex
partial SE. (Meiekord H et al, EFNS guideline on the management of
status epilepticus in adults, Eur Journal 2010)
38. Levetiracetam
• Levetiracetam has been used to control SE, typically
as second line drug.
• Levels peak within 2 hrs. Steady state in 2 days. No
significant interactions.
• Mishra et al (2012) used LEV 20 mg./kg over 15 min.
and compared with Lorezepam 0.1 mg./kg over 2 to
4 min. in 79 patients. Control was comparable (76.3%
and 75.6%). 24 Hour seizure control was also similar.
But hypotension and requirement of mechanical
ventilation was significantly higher in Lorezepam
group.
39. LACOSAMIDE
• In addition to anticonvulsant property, it has shown
potential to retard kindling induced epileptogensis.
• One report shows efficacy in Nonconvulsive
SE.(Kellinghaus C et al, Epilepsy Behav 2009)
• One report showed efficacy of oral Lacosamide in
refractory convulsive SE.(Tilz C et al, Epilepsia 2010)
40. Lacosamide
• Christian et al (2010) reported successful termination
of refractory SE given 22.5 mg. diazepam, 12.5 mg.
etomidate & 5 mg. midazolam, 4 mg. lorazepam &
1500 mg. levetiracetam. Lacosamide 300 mg via per
cutaneous gastric fistula resulted in cessation of SE in
30 min.
• Kellinghaus (2009) reported successful termination
of SE with IV Lacosamide.
• However furthere large RCT are required to prove
the efficacy and safety of this drug in SE.
41. IMPORTANT POINT
• Along with emergency control of SE, maintenance
therapy should be started to prevent recurrence
of seizures.
• In patients known to have epilepsy, their usual
AED can be continued depending on serum AED
levels.
• In patients presenting for the first time as SE,
drugs like Phenytoin or Sodium Vaproate used to
control the status can be continued as
maintenance therapy.
42. EMERGING THERAPIES
• Inhalational Anaesthetic agents
(isoflurane and desflurane )
• Attractive features include efficacy, rapid onset of action,
ability to titrate according to EEG.
• Both drugs in endtidal concentrations of 1.2-5%achieved an
EEG burst suppression and termination of seizure activity
within minutes.
• However further studies are needed in this field.
Mirasattari et al, treatment of refractory status epilepticus with inhalational
anaesthetic agents : Isoflurane & Desflurane , Arch Neurology 2004
43. Shorovan M et al,The treatment of refractory status epilepticus Brain
2011
KETAMINE
• an NMDA receptor antagonist
• Experimental studies have demonstrated synergistic action of
diazepam and ketamine in termination SE.
• Efficacy in extremely refractory SE has been documented in
both children and adults.
• No cardiac depressant properties, hence doesnot cause
hypotension.
44. KETOGENIC DIET
• Diet high in fat and low in carbohydrates
• Induces ketosis in body and thought to suppress
seizures by release of Leptin.
• Exact mechanism remains unknown.
45. Steroids and Immunotherapy
• Rationale that refractory SE may be due to antibodies
directed against neural elements.
• Increasing recognition the role of inflammation in
epileptogenesis.
• SE may be the initial presenting feature of some
immune mediated encephalopathies.
Shorovan M et al,The treatment of refractory status epilepticus
Brain 2011
46. NONPHARMACOLOGICAL TREATMENTS
• Resective surgery
• Vagal nerve stimulation
• Hypothermia- decrease brain metabolism
which is neuroprotective.
• Electroconvulsive therapy - ECT-dose-1 session
daily for 3-8 days. Mechanism-not known
47. STATUS EPILEPTICUS
Rapid IV access available
NO
IM Midazolam 0.2mg/kg (max10mg)
OR
Buccal or Intranasal Midazolam
0.5mg/kg (max10mg)
YES
IV LORAZEPAM 0.1mg/kg slow push (max 4mg)
Repeat IV LORAZEPAM 0.1mg/kg
slow push
If Seizure donot
stop in 5 minutes
If Seizure donot
stop in 5 minutes,
Achieve IV access
Shift to 2nd line drugs
If Seizure donot
stop in 5 minutes
IV Phenytoin 20mg/kg @ 50mg/min
OR
IV Fosphenytoin 20mg/kg @ 150 mg/min
If Seizure donot stop in 20 minutes
If possibility of
subttherapeutic levels,
Valproate 40-60 mg/kg @ 6
mg/kg/min can be tried
If Seizure
donot stop in
10 minutes
48. Repeat IV Phenytoin 5mg/kg OR
IV Fosphenytoin 5mg/kg
IV Phenobarbitone 20mg/kg @ 100mg/min f/by 3-5
mg/kg.hr cont infusion
OR
IV Midazolam 0.2 mg/kg loading dose f/by 0.1-0.4
mg/kg/hr cont infusion
OR
IV Propofol 2mg/kg bolus f/by 2-10 mg/kg/hr cont
infusion
OR
IV Pentobarbital 5 mg/kg loading dose f/by
1-3 mg/kg/hr cont infusion
If seizure persists after 24 hrs, try emerging novel therapies: Ketamine bolus 0.5-4.5
mg/kg infusion (upto 5 mg/kg/hr ) ; Immunomodulation IV Methylprednisolone or
IVIg; Resective surgery ; Ketogenic diet ; hypothermia
Alternative
drug
Valproate 40-
60 mg/kg @ 6
mg/kg/min
Alternative
Drug
Levitiracetam
20-30mg/kg
@ 5
mg/kg/min
Seizure not
controlled
Seizure not
controlled
50. References.
• Review article-Status Epilepticus-Lawrence J .Hirsch,MD,FAAN:
Nicolas Gaspard,MD,Phd-2013
• Guidelines for evaluation and management of status
epilepticus Neurocritical Care Society 2012
• article-Status Epilepticus-Lawrence J .Hirsch,MD,FAAN: Nicolas
Gaspard,MD,Phd-2013
51. Levetiracetam IV- Efficacy and Safety
Thongplew and collegues reviewed the clinical use, efficacy, and
outcomes of intravenous levetiracetam in adults with status
epilepticus.
Results:
• 34 prescriptions for intravenous levetiracetam in patients with
status epilepticus were noted.
• All patients had at least one co-morbidity condition
• The seizure control rate was 61.8%
• 41.2% survived and had an improved status at discharge.
Neurology Asia 2013; 18(2) : 167 – 175
Intravenous levetiracetam has good efficacy and may be a good option
for status epilepticus.
52. Levetiracetam IV- Alternative to Lorazepam
Randomized, open labeled pilot study compared the efficacy and safety of
levetiracetam and lorazepam in status epilepticus.
–Patients with convulsive or subtle convulsive SE were randomized to
Levitiracetam 20 mg/kg IV over 15 min or Lorazepam 0.1 mg/kg over 2-4
min.
J Neurol. 2012 Apr;259(4):645-8
Levetiracetam Lorazepam
In first instant,
SE controlled
76.3 75.6
In those resistant,
SE controlled
70.0 88.9
24-h freedom
from seizure
79.3 67.7
Lorazepam
• Significantly higher need
of artificial ventilation
• Insignificantly higher
frequency of hypotension
For the treatment of SE, levetiracetam is an alternative to lorazepam and may
be preferred in patients with respiratory compromise and hypotension.