Status epilepticus (SE) refers to prolonged or repeated seizures without recovery between seizures. It is a medical emergency associated with high morbidity and mortality if not treated promptly. The initial treatment for SE involves benzodiazepines like lorazepam or diazepam. If seizures continue, second line drugs like fosphenytoin or valproate are used. For refractory SE, anesthetic drugs like midazolam, propofol or pentobarbital may be needed. Timely treatment is important to prevent neuronal injury, with outcomes worsening the longer seizures continue untreated.
How to manage status epilepticus, what drugs should be used and when to use what to avoid and need to know
everything you should have about status epilepticus is here.
A 31-year-old male presented with a fever for one week and seizures and altered sensorium for three days. He experienced generalized tonic-clonic seizures that were initially uncontrolled. Imaging showed findings suggestive of viral or autoimmune encephalitis. Refractory status epilepticus was diagnosed and treated with high doses of multiple antiepileptic drugs, including lacosamide, which eventually controlled the seizures. Status epilepticus is defined as a seizure that persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur. The pathophysiology involves reductions in inhibitory GABA receptors and increases in excitatory glutamate receptors over time.
This document provides guidelines for the management of status epilepticus. It defines status epilepticus as 5 minutes or more of continuous seizure activity or recurrent seizures without recovery between seizures. Status epilepticus can be classified based on age of onset, etiology, clinical features, and EEG features. Common causes include stroke, low anti-epileptic drug levels, alcohol withdrawal, anoxic brain injury, and metabolic disturbances. Initial management involves stabilization, benzodiazepine administration, and consultation with neurology if seizures continue. For refractory or subtle cases, continuous EEG monitoring, additional anti-epileptic drugs, and anesthetic drugs like midazolam or propofol may be used. Nonpharmacological
Super refractory status epilepticus. How long should we persevere? - Hirschintensivecaresociety
Super refractory status epilepticus is a rare but serious condition seen in neurointensive care units where seizures continue despite treatment with general anesthesia. The aetiology and prognosis varies, with conditions like autoimmune encephalitis from anti-N-methyl-D-aspartate receptor antibodies having a better outlook if treated early with immunotherapy and tumor removal. Intensive care management aims to control seizures, support ventilation, and treat the underlying cause like removing ovarian teratomas in anti-NMDAR encephalitis patients. While morbidity and mortality is high, complete recovery is possible even after months of status epilepticus depending on the specific cause.
The document summarizes EEG patterns seen in various encephalopathies. It describes diffuse slowing, triphasic waves, burst suppression, periodic epileptiform discharges (PLEDs, BIPLEDs, GPEDs), alpha coma, spindle coma and beta coma patterns. Specific patterns are seen in hepatic encephalopathy, uremia, Hashimoto's encephalopathy, NMDAR encephalitis, Creutzfeldt-Jakob disease, subacute sclerosing panencephalitis. Criteria for periodic discharges and electrocerebral inactivity seen in brain death are also outlined.
The document defines status epilepticus as seizure activity that continues for 30 minutes or more, or recurrent seizures without recovery in between. It can be caused by factors like febrile illness in children, anticonvulsant withdrawal, metabolic disturbances, drugs or alcohol, infections, tumors or head trauma. Treatment involves stabilizing the patient, administering benzodiazepines like lorazepam intravenously to stop seizures, followed by anti-seizure drugs like fosphenytoin or phenobarbital if needed. Complications can include cardiac, respiratory or metabolic issues if not treated promptly.
This document discusses convulsive status epilepticus (CSE). It notes that the worldwide incidence of CSE is highest in children and the elderly, with mortality rates ranging from 10.5-28% and neurological sequelae occurring in 11-16% of patients. The most common causes of CSE are listed as low anti-epileptic drug levels, stroke, alcohol withdrawal, anoxic brain injury, and metabolic disturbances. The document provides details on the definition, types, risk factors, complications, management, and treatment of CSE.
1. PLEDs (Periodic Lateralized Epileptiform Discharges) are a pattern seen on EEG characterized by periodic discharges that are lateralized to one hemisphere.
2. They are commonly seen in conditions involving acute brain injury or inflammation such as stroke, encephalitis, tumors, or hypoxic ischemic encephalopathy.
3. PLEDs are associated with a risk of seizures but generally indicate an unstable brain state that will improve over time as the underlying condition resolves. Prognosis depends on the specific cause.
How to manage status epilepticus, what drugs should be used and when to use what to avoid and need to know
everything you should have about status epilepticus is here.
A 31-year-old male presented with a fever for one week and seizures and altered sensorium for three days. He experienced generalized tonic-clonic seizures that were initially uncontrolled. Imaging showed findings suggestive of viral or autoimmune encephalitis. Refractory status epilepticus was diagnosed and treated with high doses of multiple antiepileptic drugs, including lacosamide, which eventually controlled the seizures. Status epilepticus is defined as a seizure that persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur. The pathophysiology involves reductions in inhibitory GABA receptors and increases in excitatory glutamate receptors over time.
This document provides guidelines for the management of status epilepticus. It defines status epilepticus as 5 minutes or more of continuous seizure activity or recurrent seizures without recovery between seizures. Status epilepticus can be classified based on age of onset, etiology, clinical features, and EEG features. Common causes include stroke, low anti-epileptic drug levels, alcohol withdrawal, anoxic brain injury, and metabolic disturbances. Initial management involves stabilization, benzodiazepine administration, and consultation with neurology if seizures continue. For refractory or subtle cases, continuous EEG monitoring, additional anti-epileptic drugs, and anesthetic drugs like midazolam or propofol may be used. Nonpharmacological
Super refractory status epilepticus. How long should we persevere? - Hirschintensivecaresociety
Super refractory status epilepticus is a rare but serious condition seen in neurointensive care units where seizures continue despite treatment with general anesthesia. The aetiology and prognosis varies, with conditions like autoimmune encephalitis from anti-N-methyl-D-aspartate receptor antibodies having a better outlook if treated early with immunotherapy and tumor removal. Intensive care management aims to control seizures, support ventilation, and treat the underlying cause like removing ovarian teratomas in anti-NMDAR encephalitis patients. While morbidity and mortality is high, complete recovery is possible even after months of status epilepticus depending on the specific cause.
The document summarizes EEG patterns seen in various encephalopathies. It describes diffuse slowing, triphasic waves, burst suppression, periodic epileptiform discharges (PLEDs, BIPLEDs, GPEDs), alpha coma, spindle coma and beta coma patterns. Specific patterns are seen in hepatic encephalopathy, uremia, Hashimoto's encephalopathy, NMDAR encephalitis, Creutzfeldt-Jakob disease, subacute sclerosing panencephalitis. Criteria for periodic discharges and electrocerebral inactivity seen in brain death are also outlined.
The document defines status epilepticus as seizure activity that continues for 30 minutes or more, or recurrent seizures without recovery in between. It can be caused by factors like febrile illness in children, anticonvulsant withdrawal, metabolic disturbances, drugs or alcohol, infections, tumors or head trauma. Treatment involves stabilizing the patient, administering benzodiazepines like lorazepam intravenously to stop seizures, followed by anti-seizure drugs like fosphenytoin or phenobarbital if needed. Complications can include cardiac, respiratory or metabolic issues if not treated promptly.
This document discusses convulsive status epilepticus (CSE). It notes that the worldwide incidence of CSE is highest in children and the elderly, with mortality rates ranging from 10.5-28% and neurological sequelae occurring in 11-16% of patients. The most common causes of CSE are listed as low anti-epileptic drug levels, stroke, alcohol withdrawal, anoxic brain injury, and metabolic disturbances. The document provides details on the definition, types, risk factors, complications, management, and treatment of CSE.
1. PLEDs (Periodic Lateralized Epileptiform Discharges) are a pattern seen on EEG characterized by periodic discharges that are lateralized to one hemisphere.
2. They are commonly seen in conditions involving acute brain injury or inflammation such as stroke, encephalitis, tumors, or hypoxic ischemic encephalopathy.
3. PLEDs are associated with a risk of seizures but generally indicate an unstable brain state that will improve over time as the underlying condition resolves. Prognosis depends on the specific cause.
This document discusses various types of autoimmune encephalitis. It begins by providing clues that can suggest an autoimmune cause over infectious, including a subacute onset and fluctuating course. It then covers several specific autoimmune encephalitis subtypes defined by the neuronal surface antigens involved, such as anti-NMDA receptor and anti-LGI1 encephalitis. For each subtype, it discusses clinical features, investigations, and treatment approaches. The document aims to help clinicians differentiate between autoimmune and infectious causes of encephalitis.
1. Convulsive status epilepticus has a bimodal distribution, peaking in children and the elderly, and has multiple potential causes including infections, strokes, alcohol withdrawal and brain injuries.
2. Mortality rates range from 10.5-28% and neurological sequelae occur in 11-16% of patients. Refractory status epilepticus is defined as continuing despite benzodiazepines and other anticonvulsants.
3. Treatment involves terminating seizures acutely with benzodiazepines like lorazepam and diazepam. For refractory cases, second line drugs like phenytoin, fosphenytoin, valproate, levetirac
Multiple system atrophy is a rare, fatal neurodegenerative disease characterized by parkinsonian or cerebellar features and autonomic dysfunction. It is caused by the accumulation of alpha-synuclein protein in oligodendrocytes throughout the brain and spinal cord. There are no disease-modifying treatments available, so management focuses on alleviating motor symptoms and addressing problems related to autonomic failure and other non-motor issues.
This document discusses status epilepticus, which is defined as either continuous seizure activity lasting more than 5 minutes or two or more sequential seizures without full recovery between seizures. Status epilepticus can be caused by factors like medication noncompliance, ethanol withdrawal, infection, trauma, tumors, or stroke. The goals of managing status epilepticus are terminating seizure activity, preventing recurrence, treating underlying causes, and managing complications. Treatment involves rapid-acting anticonvulsants like diazepam or lorazepam followed by longer-acting drugs via intravenous infusion if needed. Potential complications include metabolic abnormalities, autonomic issues, renal failure, and cardiac or respiratory problems.
Recent guidelines for management of status epilepticusAbhignaBabu
This document provides guidelines for the management of status epilepticus (SE), which is defined as continuous seizure activity lasting 5 minutes or more, or recurrent seizures without recovery between seizures. It describes the types of SE, causes, initial steps, and pharmacotherapy management. The principal goals are to stop seizure activity and treat any underlying cause. Initial treatment involves benzodiazepines, followed by anticonvulsants if needed. For refractory SE lasting over 40 minutes, anesthetic doses of medications may be required. The guidelines outline stabilization, initial therapy, second therapy, and third therapy phases for treatment.
Progressive supranuclear palsy (PSP) is a rare neurodegenerative disease characterized by progressive supranuclear ophthalmoplegia, gait disturbance, postural instability, and cognitive and behavioral changes. It is caused by tau protein deposits in the brain and is the most common form of atypical parkinsonism. There is no cure for PSP and treatment aims to manage symptoms, though investigational therapies targeting tau are being explored. The prognosis is poor, with most patients becoming dependent within 3-4 years and median survival of 6-12 years after diagnosis.
Dravet syndrome is a rare and severe form of epilepsy that begins in infancy. It is characterized by frequent febrile seizures in the first year of life followed by other types of seizures and developmental delays. Genetic testing reveals mutations in the SCN1A gene in many patients. Treatment involves medications like valproate and benzodiazepines as well as a ketogenic diet, but seizures often remain difficult to control. The prognosis includes permanent neurological and cognitive impairments.
This document outlines the surgical management of epilepsy. It discusses indications for epilepsy surgery including intractable seizures, side effects of medication, and quality of life issues. The goals of surgery are to eliminate or decrease seizures and prevent neurological deficits while improving quality of life. Extensive presurgical evaluation includes imaging, EEG, neurological assessments, and sometimes invasive monitoring. Surgery targets the seizure focus and may include resective procedures or disconnections. Radiosurgery and neurostimulation are also discussed as alternative options.
This PPT focuses on the diagnosis and treatment of the primary headache disorders, with special emphasis on migraine, the headache most likely to bring patients to physicians and pharmacists. warning signs of the ominous headache, which, although rare, can herald a life-threatening condition. Clinical characteristics of the primary headache types, migraine, tension-type headache, and cluster headache, are described
Myoclonus is characterized by brief, involuntary muscle contractions or inhibitions. It can be classified anatomically based on its physiological origin in the cortex, subcortex, or periphery. Clinically, myoclonus is classified as physiological, essential, epileptic, or secondary. Treatment involves addressing the underlying cause, with anti-seizure medications often used for cortical or cortical-subcortical myoclonus, and benzodiazepines or botulinum toxin injections for other types.
This document discusses the definition, diagnosis, and treatment of refractory epilepsy. It defines refractory epilepsy as the absence of seizure control despite two or more antiepileptic drugs. Treatment options discussed include dietary therapies like the ketogenic diet, herbal medicines, surgical procedures, vagus nerve stimulation, deep brain stimulation, and responsive neurostimulation. Surgical options aim to remove or disable the epileptic focus and can reduce seizures in many patients. Vagus nerve stimulation and other devices provide seizure reduction for some patients but do not cure epilepsy. Dietary therapies and surgery offer the highest chances of improved seizure control or possible cure in refractory epilepsy cases.
This document provides an overview of spinocerebellar ataxia (SCA). It discusses the genetics, neuropathology, epidemiology, clinical features, and mechanisms of several SCA subtypes including SCA1, SCA2, SCA3, SCA6, SCA7, and SCA12. The main points are that SCA is a genetically heterogeneous group of neurodegenerative disorders characterized by progressive ataxia, with specific subtypes associated with additional symptoms depending on the mutated gene. The document reviews the genetic causes and typical features of several major SCA subtypes.
Movement disorders are not only realm of chronic disorders that are treated without requiring emergent intervention, but also they can present acutely with more aggressive forms
1) The document discusses various syndromes that can result from lesions or occlusions in different parts of the posterior circulation arteries that supply the brainstem and cerebellum.
2) Specific syndromes are described based on the location of the lesion, including PCA, vertebral artery, and basilar artery syndromes. Onset, signs and symptoms on both sides of the lesion are outlined.
3) Midbrain, pontine, and medullary syndromes are also detailed. Bilateral lesions causing Anton's syndrome and Balint's syndrome are mentioned. A variety of resulting neurological deficits are associated with different posterior circulation artery occlusions.
Epileptic encephalopathies are a group of epileptic disorders that cause cognitive and behavioral impairments beyond what would be expected from seizures alone. They typically begin early in life and are characterized by frequent seizures and abnormal EEG patterns. Common types include early myoclonic encephalopathy, Ohtahara syndrome, West syndrome, Dravet syndrome, and Lennox-Gastaut syndrome. These disorders can cause developmental delays, intellectual disabilities, and in some cases early death. Treatment aims to control seizures, though many types are highly treatment resistant.
This document discusses peripheral neuropathy and provides guidance on evaluating and diagnosing peripheral nerve disorders. It defines peripheral neuropathy as disorders affecting the peripheral nervous system, which can involve sensory nerves, motor nerves, or both. The document outlines that peripheral neuropathies can be classified based on whether they primarily affect the cell body, myelin, or axon. It also lists common causes of peripheral neuropathy like diabetes, paraproteinemia, alcohol misuse, and vitamin B12 deficiency. The document provides guidance on clinical assessment, laboratory and electrodiagnostic testing, skin or nerve biopsy, and treatment approaches for peripheral neuropathy.
1. Status epilepticus (SE) is a medical emergency defined as a seizure lasting more than 5 minutes or recurrent seizures without regaining consciousness. SE can be convulsive or non-convulsive.
2. The annual incidence of SE is estimated to be between 9,000-14,000 new cases per year in the UK. Mortality is about 20-30% and is higher in the elderly.
3. SE is initially treated with benzodiazepines like lorazepam or diazepam. If seizures continue, second line drugs like fosphenytoin or phenytoin are used. For refractory SE, anesthetic drugs under ICU care may be required
This document provides diagnostic criteria for chronic inflammatory demyelinating polyneuropathy (CIDP), including:
1) Clinical criteria for typical and atypical CIDP with inclusion/exclusion factors.
2) Definite, probable, and possible electrophysiological criteria involving compound muscle action potential tests.
3) Supportive diagnostic criteria including cerebrospinal fluid analysis, MRI findings, nerve conduction studies, and nerve biopsy results.
It also outlines inclusion/exclusion criteria and supportive criteria specifically for diagnosing pure sensory CIDP without motor involvement.
Status epilepticus is a life-threatening condition defined as a seizure lasting more than 5 minutes or recurrent seizures without regaining consciousness. It can be caused by changes in medication, infection, stroke, or other medical conditions. Symptoms include muscle spasms, confusion, and impaired consciousness. Diagnosis involves examination and electroencephalography. Treatment goals are resuscitation, terminating seizures, decreasing cerebral metabolism, and treating underlying causes. First-line treatments are benzodiazepines while refractory cases may require barbiturates, propofol, or midazolam infusion. Prognosis depends on duration and cause, with prolonged seizures carrying higher mortality and worse outcomes.
Hashimoto encephalopathy is a rare autoimmune disease characterized by encephalopathy and positive antithyroid antibody titers. It presents with a variety of neurological symptoms including seizures, involuntary movements, cognitive dysfunction, and psychiatric disorders. Diagnosis is made through exclusion of other causes and presence of elevated antithyroid antibodies with neurological symptoms. Treatment involves immunomodulation primarily with corticosteroids, though some patients may require additional immunosuppressants. While most patients improve with treatment, relapse is common and persistent neurological deficits occur in some.
This document discusses the management of pediatric status epilepticus. It defines status epilepticus as continuous seizure activity lasting more than 30 minutes or two or more sequential seizures without recovery of consciousness. Management involves early treatment with benzodiazepines like midazolam or lorazepam. If seizures continue, second-line treatments including fosphenytoin, phenytoin, valproate, or phenobarbital are used. Refractory status epilepticus is defined as continuous seizures lasting over 60 minutes despite initial treatment. It requires intensive care management including anesthetic agents like propofol to induce burst suppression on EEG.
This document summarizes information about multiple system atrophy (MSA). MSA is a neurodegenerative disorder characterized by autonomic failure and motor symptoms. It has an estimated incidence of 0.6-0.7 per 100,000 people per year. Common features include parkinsonism in at least 90% of patients, orthostatic hypotension, and urinary dysfunction in over 80% of cases. The document discusses the types of tremors seen in MSA, respiratory issues like stridor, and prognostic factors like the presence of urinary incontinence which are associated with shorter survival times.
This document discusses various types of autoimmune encephalitis. It begins by providing clues that can suggest an autoimmune cause over infectious, including a subacute onset and fluctuating course. It then covers several specific autoimmune encephalitis subtypes defined by the neuronal surface antigens involved, such as anti-NMDA receptor and anti-LGI1 encephalitis. For each subtype, it discusses clinical features, investigations, and treatment approaches. The document aims to help clinicians differentiate between autoimmune and infectious causes of encephalitis.
1. Convulsive status epilepticus has a bimodal distribution, peaking in children and the elderly, and has multiple potential causes including infections, strokes, alcohol withdrawal and brain injuries.
2. Mortality rates range from 10.5-28% and neurological sequelae occur in 11-16% of patients. Refractory status epilepticus is defined as continuing despite benzodiazepines and other anticonvulsants.
3. Treatment involves terminating seizures acutely with benzodiazepines like lorazepam and diazepam. For refractory cases, second line drugs like phenytoin, fosphenytoin, valproate, levetirac
Multiple system atrophy is a rare, fatal neurodegenerative disease characterized by parkinsonian or cerebellar features and autonomic dysfunction. It is caused by the accumulation of alpha-synuclein protein in oligodendrocytes throughout the brain and spinal cord. There are no disease-modifying treatments available, so management focuses on alleviating motor symptoms and addressing problems related to autonomic failure and other non-motor issues.
This document discusses status epilepticus, which is defined as either continuous seizure activity lasting more than 5 minutes or two or more sequential seizures without full recovery between seizures. Status epilepticus can be caused by factors like medication noncompliance, ethanol withdrawal, infection, trauma, tumors, or stroke. The goals of managing status epilepticus are terminating seizure activity, preventing recurrence, treating underlying causes, and managing complications. Treatment involves rapid-acting anticonvulsants like diazepam or lorazepam followed by longer-acting drugs via intravenous infusion if needed. Potential complications include metabolic abnormalities, autonomic issues, renal failure, and cardiac or respiratory problems.
Recent guidelines for management of status epilepticusAbhignaBabu
This document provides guidelines for the management of status epilepticus (SE), which is defined as continuous seizure activity lasting 5 minutes or more, or recurrent seizures without recovery between seizures. It describes the types of SE, causes, initial steps, and pharmacotherapy management. The principal goals are to stop seizure activity and treat any underlying cause. Initial treatment involves benzodiazepines, followed by anticonvulsants if needed. For refractory SE lasting over 40 minutes, anesthetic doses of medications may be required. The guidelines outline stabilization, initial therapy, second therapy, and third therapy phases for treatment.
Progressive supranuclear palsy (PSP) is a rare neurodegenerative disease characterized by progressive supranuclear ophthalmoplegia, gait disturbance, postural instability, and cognitive and behavioral changes. It is caused by tau protein deposits in the brain and is the most common form of atypical parkinsonism. There is no cure for PSP and treatment aims to manage symptoms, though investigational therapies targeting tau are being explored. The prognosis is poor, with most patients becoming dependent within 3-4 years and median survival of 6-12 years after diagnosis.
Dravet syndrome is a rare and severe form of epilepsy that begins in infancy. It is characterized by frequent febrile seizures in the first year of life followed by other types of seizures and developmental delays. Genetic testing reveals mutations in the SCN1A gene in many patients. Treatment involves medications like valproate and benzodiazepines as well as a ketogenic diet, but seizures often remain difficult to control. The prognosis includes permanent neurological and cognitive impairments.
This document outlines the surgical management of epilepsy. It discusses indications for epilepsy surgery including intractable seizures, side effects of medication, and quality of life issues. The goals of surgery are to eliminate or decrease seizures and prevent neurological deficits while improving quality of life. Extensive presurgical evaluation includes imaging, EEG, neurological assessments, and sometimes invasive monitoring. Surgery targets the seizure focus and may include resective procedures or disconnections. Radiosurgery and neurostimulation are also discussed as alternative options.
This PPT focuses on the diagnosis and treatment of the primary headache disorders, with special emphasis on migraine, the headache most likely to bring patients to physicians and pharmacists. warning signs of the ominous headache, which, although rare, can herald a life-threatening condition. Clinical characteristics of the primary headache types, migraine, tension-type headache, and cluster headache, are described
Myoclonus is characterized by brief, involuntary muscle contractions or inhibitions. It can be classified anatomically based on its physiological origin in the cortex, subcortex, or periphery. Clinically, myoclonus is classified as physiological, essential, epileptic, or secondary. Treatment involves addressing the underlying cause, with anti-seizure medications often used for cortical or cortical-subcortical myoclonus, and benzodiazepines or botulinum toxin injections for other types.
This document discusses the definition, diagnosis, and treatment of refractory epilepsy. It defines refractory epilepsy as the absence of seizure control despite two or more antiepileptic drugs. Treatment options discussed include dietary therapies like the ketogenic diet, herbal medicines, surgical procedures, vagus nerve stimulation, deep brain stimulation, and responsive neurostimulation. Surgical options aim to remove or disable the epileptic focus and can reduce seizures in many patients. Vagus nerve stimulation and other devices provide seizure reduction for some patients but do not cure epilepsy. Dietary therapies and surgery offer the highest chances of improved seizure control or possible cure in refractory epilepsy cases.
This document provides an overview of spinocerebellar ataxia (SCA). It discusses the genetics, neuropathology, epidemiology, clinical features, and mechanisms of several SCA subtypes including SCA1, SCA2, SCA3, SCA6, SCA7, and SCA12. The main points are that SCA is a genetically heterogeneous group of neurodegenerative disorders characterized by progressive ataxia, with specific subtypes associated with additional symptoms depending on the mutated gene. The document reviews the genetic causes and typical features of several major SCA subtypes.
Movement disorders are not only realm of chronic disorders that are treated without requiring emergent intervention, but also they can present acutely with more aggressive forms
1) The document discusses various syndromes that can result from lesions or occlusions in different parts of the posterior circulation arteries that supply the brainstem and cerebellum.
2) Specific syndromes are described based on the location of the lesion, including PCA, vertebral artery, and basilar artery syndromes. Onset, signs and symptoms on both sides of the lesion are outlined.
3) Midbrain, pontine, and medullary syndromes are also detailed. Bilateral lesions causing Anton's syndrome and Balint's syndrome are mentioned. A variety of resulting neurological deficits are associated with different posterior circulation artery occlusions.
Epileptic encephalopathies are a group of epileptic disorders that cause cognitive and behavioral impairments beyond what would be expected from seizures alone. They typically begin early in life and are characterized by frequent seizures and abnormal EEG patterns. Common types include early myoclonic encephalopathy, Ohtahara syndrome, West syndrome, Dravet syndrome, and Lennox-Gastaut syndrome. These disorders can cause developmental delays, intellectual disabilities, and in some cases early death. Treatment aims to control seizures, though many types are highly treatment resistant.
This document discusses peripheral neuropathy and provides guidance on evaluating and diagnosing peripheral nerve disorders. It defines peripheral neuropathy as disorders affecting the peripheral nervous system, which can involve sensory nerves, motor nerves, or both. The document outlines that peripheral neuropathies can be classified based on whether they primarily affect the cell body, myelin, or axon. It also lists common causes of peripheral neuropathy like diabetes, paraproteinemia, alcohol misuse, and vitamin B12 deficiency. The document provides guidance on clinical assessment, laboratory and electrodiagnostic testing, skin or nerve biopsy, and treatment approaches for peripheral neuropathy.
1. Status epilepticus (SE) is a medical emergency defined as a seizure lasting more than 5 minutes or recurrent seizures without regaining consciousness. SE can be convulsive or non-convulsive.
2. The annual incidence of SE is estimated to be between 9,000-14,000 new cases per year in the UK. Mortality is about 20-30% and is higher in the elderly.
3. SE is initially treated with benzodiazepines like lorazepam or diazepam. If seizures continue, second line drugs like fosphenytoin or phenytoin are used. For refractory SE, anesthetic drugs under ICU care may be required
This document provides diagnostic criteria for chronic inflammatory demyelinating polyneuropathy (CIDP), including:
1) Clinical criteria for typical and atypical CIDP with inclusion/exclusion factors.
2) Definite, probable, and possible electrophysiological criteria involving compound muscle action potential tests.
3) Supportive diagnostic criteria including cerebrospinal fluid analysis, MRI findings, nerve conduction studies, and nerve biopsy results.
It also outlines inclusion/exclusion criteria and supportive criteria specifically for diagnosing pure sensory CIDP without motor involvement.
Status epilepticus is a life-threatening condition defined as a seizure lasting more than 5 minutes or recurrent seizures without regaining consciousness. It can be caused by changes in medication, infection, stroke, or other medical conditions. Symptoms include muscle spasms, confusion, and impaired consciousness. Diagnosis involves examination and electroencephalography. Treatment goals are resuscitation, terminating seizures, decreasing cerebral metabolism, and treating underlying causes. First-line treatments are benzodiazepines while refractory cases may require barbiturates, propofol, or midazolam infusion. Prognosis depends on duration and cause, with prolonged seizures carrying higher mortality and worse outcomes.
Hashimoto encephalopathy is a rare autoimmune disease characterized by encephalopathy and positive antithyroid antibody titers. It presents with a variety of neurological symptoms including seizures, involuntary movements, cognitive dysfunction, and psychiatric disorders. Diagnosis is made through exclusion of other causes and presence of elevated antithyroid antibodies with neurological symptoms. Treatment involves immunomodulation primarily with corticosteroids, though some patients may require additional immunosuppressants. While most patients improve with treatment, relapse is common and persistent neurological deficits occur in some.
This document discusses the management of pediatric status epilepticus. It defines status epilepticus as continuous seizure activity lasting more than 30 minutes or two or more sequential seizures without recovery of consciousness. Management involves early treatment with benzodiazepines like midazolam or lorazepam. If seizures continue, second-line treatments including fosphenytoin, phenytoin, valproate, or phenobarbital are used. Refractory status epilepticus is defined as continuous seizures lasting over 60 minutes despite initial treatment. It requires intensive care management including anesthetic agents like propofol to induce burst suppression on EEG.
This document summarizes information about multiple system atrophy (MSA). MSA is a neurodegenerative disorder characterized by autonomic failure and motor symptoms. It has an estimated incidence of 0.6-0.7 per 100,000 people per year. Common features include parkinsonism in at least 90% of patients, orthostatic hypotension, and urinary dysfunction in over 80% of cases. The document discusses the types of tremors seen in MSA, respiratory issues like stridor, and prognostic factors like the presence of urinary incontinence which are associated with shorter survival times.
Dr. john millichap kcnq2 Cure summit professional track learn more at kcnq2cu...scottyandjim
Dr. John Millichap speaking at 2014 Denver KCNQ2 Cure summit professionals track at Children's Hospital of Colorado. More information at www.kcnq2cure.org
Brief overview of hypokinetic movement disorderAhmad Shahir
This document provides an overview of hypokinetic movement disorders, specifically focusing on Parkinson's disease. It defines hypokinetic movements as abnormal movements involving initiation, implementation, velocity, frequency or posture. It then discusses Parkinson's disease in more detail, covering its epidemiology, aetiology, clinical presentations, investigations, available treatments, and prognosis. Key points include that Parkinson's disease is the second most common neurodegenerative disorder, involves the loss of dopaminergic neurons, and can be diagnosed clinically. Treatment involves pharmacological therapies like levodopa as well as non-pharmacological options such as deep brain stimulation for advanced cases.
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
A review of epilepsy in the elderly, the etiopathogenesis, clinical challenges, diagnosis, use of antiseizure drugs and outcomes. Also the various special considerations in managing elderly patients with epilepsy.
Epilepsy is a common neurological disorder in the elderly population. Incidence and prevalence of both seizures and epilepsy are highest in those over age 75. The most common causes of epilepsy in the elderly are cerebrovascular disease, brain tumors, and dementia. Seizures may present differently in elderly patients, often appearing as subtle changes in mental status rather than overt convulsions. Treatment involves identifying and managing the underlying cause, with antiseizure drugs chosen based on safety and tolerability over efficacy due to increased risk of interactions and side effects. Careful dosing and monitoring is needed due to age-related changes in pharmacokinetics and pharmacodynamics.
Seizures in children, dr.amit vatkar, pediatric neurologistDr Amit Vatkar
This document provides information about pediatric epilepsy from Dr. Amit Vatkar, a pediatric neurologist. It discusses the types of epilepsy according to Ayurveda, how epilepsy presents differently in children than adults, diagnostic testing and treatment options. Key points include that 70% of epilepsy starts in childhood, initial seizures are often not treated but recurrence risk is reduced with treatment, and around 67% of patients achieve remission over time, with 86% doing so without medication.
Friday Morning 10-24-14 Dr. Wheless Clinical Practice of LGSLGS Foundation
This document provides information on the clinical practice of Lennox-Gastaut Syndrome (LGS), including:
1. LGS is a severe epileptic encephalopathy characterized by multiple seizure types and cognitive decline. It accounts for 5-10% of childhood seizures and has a poor prognosis.
2. Diagnostic criteria include multiple seizure types like tonic seizures, atypical absences, and drop attacks, along with abnormal EEG patterns and cognitive impairment. Diagnosis can be challenging due to overlap with other epilepsies.
3. Treatment involves a sequential approach starting with antiepileptic drugs, and may include therapies like the ketogenic diet, vagus nerve stimulation, and epilepsy surgery if drugs are ineffective
Epileptic encephalopathies are a group of epileptic disorders that cause cognitive and behavioral impairments beyond what would be expected from seizures alone. They typically begin early in life and are characterized by frequent seizures and abnormal EEG patterns. Common types include early myoclonic encephalopathy, Ohtahara syndrome, West syndrome, Dravet syndrome, and Lennox-Gastaut syndrome. These disorders can cause developmental delays, neurological deficits, and sometimes early death if not properly treated. Management involves seizure control through medications and other therapies like the ketogenic diet.
- 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
Advances in management of seizure disorderShadab Ahmad
Seizure- a paroxysmal event due to abnormal
excessive or synchronous neuronal activity
in the brain.
Epilepsy- Recurrent seizure due to chronic
underlying process.
This document discusses various epileptic encephalopathies in infants and children. It begins by defining epileptic encephalopathies as electro-clinical syndromes associated with a high probability of encephalopathic features that present or worsen after the onset of epilepsy. It then describes several specific neonatal and infantile epileptic syndromes in detail, including early myoclonic encephalopathy, Ohtahara syndrome, West syndrome, and malignant migrating partial epilepsy of infancy. It also discusses later childhood syndromes such as Landau-Kleffner syndrome and continuous spike-wave during slow-wave sleep syndrome. For each syndrome, it covers defining characteristics, etiology, investigations, treatment approaches, and prognosis
Parkinson's disease is a progressive neurodegenerative disorder characterized by motor and non-motor symptoms. The document defines Parkinson's disease and discusses its epidemiology, types, symptoms, risk factors, complications, diagnosis, evaluation scales, management including pharmacological and non-pharmacological approaches, and patient counselling points. The disease is caused by degeneration of dopaminergic neurons and impacts mobility through motor symptoms like tremors, rigidity, and postural instability. It is generally diagnosed clinically and may be supported by imaging or neurological tests. Management focuses on symptom control through medications and lifestyle modifications.
A child presented with seizures requires a systematic evaluation and management approach. Status epilepticus is a medical emergency associated with significant morbidity and mortality. Antiepileptic drug treatment depends on the seizure type and syndrome classification. Febrile seizures are common in children under age 5 and usually have a benign prognosis.
SSPE, dr. amit vatkar, pediatric neurologistDr Amit Vatkar
Subacute sclerosing pan encephalitis (SSPE) also known as Dawson Disease, Dawson encephalitis, and measles encephalitis is a rare and chronic form of progressive brain inflammation caused by a persistent infection with measles virus.
In this presentaion i will a case a sspe and give u some information regarding daignosis and treatment
1) Status epilepticus refers to prolonged or continuous seizure activity lasting more than 5 minutes. It is a medical emergency that can cause neuronal damage the longer it persists.
2) Treatment involves controlling airway and vital signs, administering glucose and thiamine, performing diagnostic tests, and starting anticonvulsant drug therapy.
3) First line drug therapy includes lorazepam or diazepam followed by phenytoin or fosphenytoin. If seizures continue, additional doses of these drugs or alternative drugs like phenobarbital are given.
This document discusses status epilepticus (SE), including:
- Definitions and types of SE such as convulsive SE, nonconvulsive SE, and acute repetitive seizures.
- Characteristics of generalized convulsive SE.
- Incidence and mortality rates of SE which increase with age.
- Main causes of SE such as low antiepileptic drug levels, cerebrovascular accidents, anoxia/hypoxia, and metabolic disturbances.
- Guidelines for the management of SE including initiating treatment with benzodiazepines like lorazepam or diazepam, followed by antiepileptic drugs like fosphenytoin, phenytoin,
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
2. Introduction
• Status epilepticus (SE) is a series of
uninterrupted seizures which result in an
impairment of normal brain function, which
if not treated as a medical emergency results
in high morbidity and mortality
• Overall annual incidence of 10-41 per
100,000 people
• Bimodal peak distribution, with peaks in
children and elderly
J K Murthy Convulsive status epilepticus API India 2013 2013
• Frequency of refractory status
epilepticus in status epilepticus patients
= 31-44% & 20% RSE will bcm SRSE
• Approximately 50% cases, there is no
prior history of epilepsy(NORSE)
• Mortality rates range between 10.5-28%
for SE
• Neurological or cognitive sequelae in
convulsive SE occur in 11- 16 % patients
3. Definition
• SE was defined as more than 30 min of either
• (1) continuous seizure activity or
• (2) two or more sequential seizures without full recovery of consciousness
between them
• The International League Against Epilepsy (ILAE)
• Operational definition of SE, which suggests starting treatment if
seizures do not spontaneously stop within 5 min
4. The new definition of SE
• SE is a condition resulting either from the failure of the mechanisms
responsible for seizure termination
or
• From the initiation of mechanisms that lead to abnormally prolonged
seizures (after time point t1).
• It is a condition that can have long-term consequences (after time
point t2)
• Including neuronal death, neuronal injury, and alteration of neuronal networks,
depending on the type and duration of seizures
5. Classification of SE
With prominent motor symptoms
Convulsive SE (CSE, synonym: tonic–clonic SE)
• Generalized convulsive
• Focal onset evolving into bilateral convulsive SE
• Unknown whether focal or generalized
Myoclonic SE (prominent epileptic myoclonic jerks) With coma
& Without coma
Focal motor
• Repeated focal motor seizures (Jacksonian)
• Epilepsia partialis continua (EPC)
• Adversive status
• Oculoclonic status
• Ictal paresis (i.e., focal inhibitory SE)
Tonic status
Hyperkinetic SE
Without prominent motor symptoms
• NCSE with coma
• NCSE without coma
• Typical absence status
• Atypical absence status
• Myoclonic absence status
• Focal a Without impairment of consciousness (aura continua,
with autonomic, sensory, visual, olfactory, gustatory, emotional/psychic/experiential, or
auditory symptoms)
• Aphasic status
• With impaired consciousness
• Unknown whether focal or generalized
• Autonomic SE
6. Etiology of SE
• Known (i.e., symptomatic)
• Acute (e.g., stroke, intoxication, malaria, encephalitis, etc.)
• Remote (e.g., posttraumatic, postencephalitic, poststroke, etc.)
• Progressive (e.g., brain tumor, Lafora’s disease and other PMEs,dementias)
• SE in defined electroclinical syndromes
• Unknown (i.e., cryptogenic)
7. Epidemiology of status epilepticus in adults: A population‐based
study on incidence, causes, and outcomes (26 November 2018)
0
8.
9. Etiology in SE
• According to an Indian study, the etiology of SE
• 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) 257:224-2292013
10. Systemic and cerebral pathophysiological changes associated with
seizures and convulsive status epilepticus
Compensation (< 30 minutes)
• Increased cerebral blood flow
• Cerebral energy requirements matched by
supply of oxygen and glucose
• Increased glucose concentration in the
brain
• Increased catecholamine release
• Increased cardiac output
Decompensation (> 30 minutes)
• Failure of cerebral autoregulation
• Hypoglycaemia
• Hypoxia
• Acidosis
• Hyponatraemia
• Hypo/hyperkalaemia
• Disseminated intravascular coagulation
• Leucocytosis
• Falling blood pressure
• Falling cardiac output
• Rhabdomyolysis
11. Most sz stop, why
some will progress
to SE/RSE
Excitatory vs
Inhibitory
neurotransmitters
GABA apoptosis
within minutes of
sz onset
Loss of GABA
receptors on
neuronal surface
TIME is BRAIN
BZP, barbiturate
resistance after
initial time delay
Glutamate and
NMDA
neurotransmitter
toxicity
Neuronal death &
seizure
propagation to SE
Pathophysiology of SE
12. Time to Treatment in SE
• The sooner treatment is initiated, the better the chances of success, and
the lower the risk for adverse consequences
13. Factors associated with poor
outcome in SE
• Duration of seizures (most important)
• Sensorium at presentation
• Underlying aetiology (Stroke, Anoxic & infection)
• De novo development in hospitalised patients
• Older age
• Associated medical complication
• Focal neurological signs at onset
Symptomatic SE, young
patient, low AED levels
better prognosis
14. Predictor scoring in SE- STESS
Status Epilepticus Severity Score (STESS) A tool to orient early treatment strategy J Neurol (2008) 255:1561–1566
15. Predictor scoring in EMSE- EACE
Epidemiology-Based Mortality Score in Status Epilepticus (EMSE) Neurocritical Care 22(2) · November 2014
16. Major drugs in SE
Drug Latency in min Duration in hours
Lorazepam IV 3-10 12-24
Diazepam rectal 5-15 <1
Diazepam IV 1-5 <1
Midazolam IV 10-30 <1
Midazolam IM/buccal 5-10 <1
Phenytoin 10-30 12-24
Fosphenytoin 10-30 12-24
Phenobarbitone 5-30 48-72
Valproate <20 8-24
17. Goals of treatment in SE
• Termination of Status Epilepticus
• Prevention of Seizure Recurrence
• Management of Precipitating cause
• Management of complications
18. Approach: Diagnostic workup
All patients
• Monitor vital signs (ABC).
• Obtain IV access
• 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
19. STATUS EPILEPTICUS
Rapid IV access available
NO
IM Midazolam 0.2mg/kg (max 10mg)
OR
Buccal or Intranasal Midazolam
0.5mg/kg (max10mg)
YES
IV LORAZEPAM 0.1mg/kg slow push (max
4mg)
Rate- maximum rate of 2 mg/minute
Repeat IV LORAZEPAM
0.1mg/kg
slow push
If Seizure donot
stop in 5 minutes
If Seizure do not 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 30 mg/kg @ 150 mg/min
If Seizure do not stop in 20 minutes
If possibility of
subttherapeutic levels,
Valproate 20-40 mg/kg @
5-10 mg/kg/min max 3 gm
If Seizure
donot stop in
10 minutes
Airway-
Breathing-
Circulation
OXYGEN
+
POSITIONING
History- AED ,
DRUGS,
TRAUMA
RBS & Blood
tests, another IV
cannula
20. PHT @ 5mg/kg or fPHT @ 7.5
mg/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 Super
refractory status epilepticus
Alternative drug
Valproate 40-
60 mg/kg @ 5-10
mg/kg/min
Alternative
Drug Levitiracetam
20-30mg/kg
@ 5 mg/kg/min
Seizure not
controlled
Seizure not
controlled
Refractory Status Epilepticus
21.
22.
23. 1998 Veteran’s Affairs SE study
Lorazepam vs Phenytoin
• Lorazepam (0.1 mg/kg), diazepam (0.15 mg/kg) followed by phenytoin (18
mg/kg), phenobarbital (18 mg/kg), and phenytoin alone (18 mg/kg) in adults
• Differential anticonvulsant efficacy was found in overt status epilepticus where
the four treatment arms had an overall difference (p = 0.02) for the primary
outcome variable.
• Only one head-to head comparison met the pre-specified statistical
significance difference: lorazepam was superior to phenytoin (p = 0.002)
Evidence-Based Guideline Epilepsy Curr. 2016 Jan-Feb; 16(1): 48–61.
24. 2001 Alldredge trial IV Lorazepam vs
Diazepam
• 205 adult patients with status epilepticus randomized to one of 3 different treatments
initiated outside the hospital by paramedics:
• IV lorazepam (2 mg, n=66)
• IV diazepam (5 mg, n=68)
• IV placebo (n=71)
• A repeat dose of study drug could be done if the seizure continued after 4 minutes
(for a maximum lorazepam dose of 4 mg and diazepam dose of 10 mg)
• Both lorazepam and diazepam were superior to placebo:
lorazepam (59.1%) > placebo (21.1%) (OR, 4.8; 95% CI: 1.9–13.0)
diazepam (42.6%) > placebo (21.1%) (OR, 2.3; 95% CI: 1.0–5.9)
Evidence-Based Guideline Epilepsy Curr. 2016 Jan-Feb; 16(1): 48–61.
25. 2012 RAMPART study
IM Midazolam (prehospital) vs IV
Lorazepam
• 893 participants with SE (748 adults and 145 children) were randomized to one of
two treatments in a non-inferiority comparison (pre-specified non-inferiority
margin of 10%):
• Intramuscular midazolam (10 mg or 5 mg in children weighing 13–40 kg, n=448)
• IV lorazepam (4 mg or 2 mg in children weighing 13–40 kg, n=445)
• Primary efficacy endpoint was achieved in 73% of subjects in the IM
midazolam group compared with 63% in the IV lorazepam group giving an
absolute difference between groups of 10% (95% CI: 4.0–16.1)
Evidence-Based Guideline Epilepsy Curr. 2016 Jan-Feb; 16(1): 48–61.
26. VA vs other AEDs RCTs
• Five open-label class III initial therapy RCTs examined the efficacy of
• IV valproic acid (n = 2) , IV phenytoin (n = 2) , IV phenobarbital (n = 1), IV
diazepam plus phenytoin (n = 1) , IV levetiracetam (n = 1) , rectal diazepam
(n = 1) , and IV lorazepam (n = 1)
• Valproic acid had higher efficacy than phenytoin in one study
(valproic acid, 66%, vs phenytoin, 42%; p = 0.046)
Sodium valproate vs phenytoin in status epilepticus: a pilot study. Misra UK, Kalita J, Patel R Neurology. 2006 Jul 25; 67(2):340-2
• VA similar to phenytoin in the other (valproic acid, 87.8%, vs
phenytoin, 88%)
Treatment of status epilepticus and acute repetitive seizures with i.v. valproic acid vs phenytoin Acta Neurol Scand. 2008
27. • IM midazolam, IV lorazepam, IV diazepam (with or without phenytoin) are
established as efficacious at stopping seizures lasting at least 5 minutes (level A).
• IM midazolam has superior effectiveness compared with IV lorazepam in adults
with convulsive status epilepticus without established IV access (level A).
• IV lorazepam is more effective than IV phenytoin in stopping seizures lasting at
least 10 minutes (level A).
Conclusion of studies
Evidence-Based Guideline Epilepsy Curr. 2016 Jan-Feb; 16(1): 48–61.
28. Conclusion of studies
• IV valproic acid has similar efficacy to IV phenytoin or continuous IV diazepam
as second therapy after failure of a benzodiazepine (level C).
• Insufficient data exist in adults about the efficacy of levetiracetam as either initial
or second therapy (level U).
Evidence-Based Guideline Epilepsy Curr. 2016 Jan-Feb; 16(1): 48–61.
29. Is IV Fosphenytoin More Effective
Than IV Phenytoin?
• A Class III single-dose, randomized, double-blind, class III tolerability study in patients
needing infusion of phenytoin compared
• Insufficient data exist about the comparative efficacy of phenytoin and fosphenytoin
(level U).
• Fosphenytoin is better tolerated compared with phenytoin (level B).
• When both are available, fosphenytoin is preferred based on tolerability, but phenytoin is
an acceptable alternative (level B)
Evidence-Based Guideline Epilepsy Curr. 2016 Jan-Feb; 16(1): 48–61.
30. 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
31. When Does Anticonvulsant Efficacy
Drop Significantly
• The efficacy of each successive blinded treatment was:
First AED 55.5%
Second AED 7.0%
Third AED 2.3%
Four or more AEDs 23.2%
No AED was successful 11.7%
• If the patient did not respond to lorazepam or phenytoin, the response rate to 3rd
AED was 2.3%
• the second anticonvulsant administered is less effective than the first “standard”
anticonvulsant, while the third anticonvulsant administered is substantially less
effective than the first “standard” anticonvulsant (level A).
After How Many Different Anticonvulsants Does Status Epilepticus Become Refractory?
1998 class I Veterans Affairs SE study
32. Refractory & Super-refractory SE
• Refractory status epilepticus -either clinical or electrographic seizures that
persist after adequate doses of an initial benzodiazepine and an acceptable
second-line antiseizure drug
• Super-refractory status epilepticus -seizures continue to recur 24hours or
more after the onset of anasthetic therapy
• Acute repetitive seizures- 3 or more seizures within 24 hours for patients
whose habitual seizure frequency is fewer than 3 seizures/day with
relatively preserved sensorium in between
33. Refractory status epilepticus
• Up to 23 - 30 % status epilepticus will turn out refractory, standard
definition 30-60 min will prolong neuronal injury
• Failure to respond to second AED (proper dose) should be treated as
RSE
34. Refractory status epilepticus
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
Review history
Examine for any
focality
Check records
Check dose and Drug
Counsel family
ICU call and shift
35.
36. C-EEG in RSE
• Need for Continuous EEG
• 15- 20 % will bcm NCSE
• Difficult to differentiate post ictal vs NCSE
• Electromechanical dissociation in subtle GCS
• To titrate dose of IV anaesthetics
• Decide when to taper AEDs
• C-EEG should be started within 1 hours with frequent review
• EEG bursts are associated with phasic synaptic depolarizing cellular potentials (Action
potential)
• Target of EEG is to achieve burst suppression pattern
37. Burst suppression EEG
• EEG - brief bursts of spikes, sharp waves, or
slow waves of relatively high amplitude
alternating with periods of relatively flat EEG
or isoelectric period (usually >10 s IBI, <
10mvolt)
• No association between a specific interburst
interval and outcome has been identified
• Targeting clinical seizures is most important
• EEG characteristics of the bursts
rather than IBI on C-EEG
• Percent of bursts with epileptiform
features
• Maximum amplitude of bursts and
monomorphic bursts
• Burst suppression ratio or IBI doesn’t
effect outcome
EEG Characteristics of Successful Burst Suppression for Refractory Status Epilepticus Neuro crit 2016
Does burst-suppression achieve seizure control in refractory status epilepticus? BMC
Neurology 2017
Burst suppression doesn’t correlate with outcome or recurrence in RSE
38. Treatment of resistant SE
Drug Loading dose Maintenance dose Side effects
Midazolam 0.2–0.4 mg/kg
IV every 5 min until
Seizures controlled.
Maximum dose:
2 mg/kg
0.1–2.0 mg/kg/h Respiratory
depression,
hypotension
Propofol 2 mg/kg IV every 5 min
until seizures controlled.
Maximum dose:
10 mg/kg
30–200 mcg/kg/min
Avoid ≥ 80 mcg/kg/min
for ≥ 48 h
Hypotension, propofol infusion
Syndrome (PRIS)
Movement ds
Pentobarbitol 5 mg/kg IV up to 50 mg/min
every 5 min until seizures
are controlled or a
Maximum loading dose
of 15 mg/kg
0.5–5 mg/kg/h Hypotension, adynamic
ileus, respiratory
depression, hepatotoxicity,
Prolonged sedation
Ketamine 1 mg/kg loading
Maximum 5mg/kg
0.5 to 10 mg/kg/hour Hypertension, hallucination,
arrhythmia, increased ICP
39. Midazolam
• Rapidly acting, short duration 0.8 to 2.8 hours
• Most commonly used 3rd line agent, commonly available
• Associated with tachyphylaxis, necessitating gradually higher doses.
• Hypotension in 40-50 % and respiratory depression needs support
• 51% of patients had breakthrough seizures within the first 6 h of MDZ
treatment (vs 15% on propofol and 12% on pentobarbital)
• 63% of patients had withdrawal seizures when tapering MDZ (compared to
46% on propofol and 43% on pentobarbital)
High-dose midazolam infusion for refractory status epilepticus. Neurology 2014
40. Propofol
• Propofol IV anesthetic acts by direct activation of GABA-A receptors ,
inhibition of NMDA receptors.
• Rapid onset of action - decreases cerebral oxygen utilization - reduces ICP
• Hypotension required pressors in 22– 55% of patients.
• Propofol infusion syndrome (PRIS) - metabolic acidosis, rhabdomyolysis,
renal failure, hypertriglyceridemia, refractory bradycardia, and cardiac
failure
41. Barbiturates
• Thiopental & Pentobarbitone (active metabolite of thiopental)
• Augmenting transmission at the GABA receptor
• Lower body temperature - may have neuroprotective effects
• High doses - loss of brainstem reflexes and an isoelectric pattern on
EEG & long duration of effect
• Strong anaesthetic agent, almost always controls seizures up to 90 %
pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study. Crit Car 2014
42. Role of Ketogenic diet
The Feasibility, Safety and Efectiveness of a Ketogenic Diet for Refractory Status Epilepticus in Adults in the Intensive Care Unit Neurocrit Care 2018
ketogenic diet (KD), a low carbohydrate diet that promotes
formation of ketone bodies (e.g., acetoacetate and beta
hydroxybutyrate)
ketogenic diet as a formula delivered via feeding tube
Once able to tolerate food by mouth, patients switched to a
modified Atkins diet
Although the study in children and adolescents is RCT, it is open
label and relies on parental reporting both of seizure frequency
and severity
43. Role of Ketogenic diet
• KD initiation and implementation is not always practical
• Randomized placebo controlled studies are needed to fully determine
if KD is safe and effective among patients with SRSE
• KD can be considered in pediatric patients in limited options but need
further well powered studies
44. Autoimmunity in SE
New-onset refractory status epilepticus or NORSE
Febrile infection-related epilepsy syndrome (FIRES) 40 % Refractory status epilepticus
Devastating epileptic encephalopathy in school-aged children (DESC)
(1) status epilepticus as presentation of new-onset seizures
(2) progression to refractory or super-refractory status epilepticus
(3) relatively recent but explosive onset of seizures
(4) the absence of established epilepsy history
(5) the presence of other neurological problems such as memory loss, autonomic or hypothalamic dysfunction, and ataxia or
movement disorder
(6) new psychiatric symptoms or behavioral changes
(7) known history of cancer
(8) lymphocytic pleocytosis on CSF examination
45. Autoimmunity in SE
Hashimoto encephalopathy and Rasmussen
encephalitis present with refractory status
epilepticus
CSF can be normal in up to 40–50% of
the patients
Treated best with Steroids/PLEX/IvIg
APE score of 4 or greater had a sensitivity of
82.6% and a specificity of 82.0% for detecting a
positive antibody
RITE
score of 7 or greater predicted a favorable
seizure outcome and had a sensitivity
of 87.5% and specificity of 83.8%
47. Management of NCSE
There is no universally accepted definition of nonconvulsive status epilepticus and there is no consensus on
how to treat it.
EEG, although critical to the evaluation of
nonconvulsive status epilepticus, can sometimes be
equivocal.
In these cases, a response to treatment (typically
IV-administered antiseizure drugs)
Patient’s clinical state, medical history, and
response to antiseizure drugs is often needed to
make the diagnosis.
Once the diagnosis of NCSE is made
How aggressively to treat ?
Patient’s mental
status and clinical course
48. EEG criteria for NCSE Salzburg
In patients without a known
epileptic encephalopathy
Repetitive generalized or focal spikes, polyspike,
sharp waves, spike-and-wave or sharp-and-slow
wave complexes at >2.5/second.
ED <2.5/second OR rhythmic delta/theta activity
And one of the below
Focal ictal phenomena (e.g., facial twitching, gaze
deviation, nystagmus, limb myoclonus)
EEG improvement after IV AED
Typical spatiotemporal evolution
In patients with known epileptic
encephalopathy
Frequent or continuous generalized spike-wave
discharges, which show an increase in profusion or
frequency when compared to baseline
EEG with observable change in clinical state.
Regression (improvement) of clinical or EEG features
with IV BZPs