The document discusses guidelines for the management of status epilepticus, dividing treatment into phases from 0-5 minutes for stabilization, 5-20 minutes for initial benzodiazepine therapy, 20-40 minutes for a second line anti-seizure medication like fosphenytoin, valproic acid, or levetiracetam, and 40-60 minutes for third line therapy if needed. Rapid treatment and identification of any underlying causes is important to prevent complications and mortality from ongoing seizures.
Status epilepticus is defined as continuous seizure activity or intermittent seizures without full recovery between seizures. It can be convulsive or non-convulsive. Initial treatment involves stabilizing the airway, breathing, and circulation, followed by benzodiazepines like lorazepam or diazepam to stop seizures. If seizures continue, second line drugs like fosphenytoin or levetiracetam are used. For refractory cases, continuous infusions of midazolam, pentobarbital or propofol may be needed. The most common adverse effect is respiratory depression, so patients require monitoring. No significant difference in effectiveness exists between lorazepam and diazepam as initial
- 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
This document provides information on the definition, classification, treatment guidelines, and management of status epilepticus. It defines status epilepticus as generalized tonic-clonic seizures lasting more than 5 minutes or focal seizures with impaired awareness lasting over 10 minutes. It classifies different types of refractory and super-refractory status epilepticus. It discusses guidelines from medical organizations on treatment. It provides details on first-line and second-line anti-seizure medications for status epilepticus, including benzodiazepines like lorazepam and midazolam, as well as levetiracetam, valproate, fosphenytoin/phenytoin, phenobarb
This document summarizes guidelines from the American Epilepsy Society and Indian Pediatrics for the treatment of status epilepticus in children and adults. It defines status epilepticus and evaluates questions around effective initial and subsequent anticonvulsant therapies. For initial treatment, lorazepam, diazepam, and midazolam are recommended benzodiazepines, with midazolam preferred without IV access. Phenytoin or fosphenytoin are suggested as second line therapies. The treatment success rates decline with each subsequent therapy, and refractory cases may require anesthetic doses of midazolam, pentobarbital, propofol or thiopental with EEG monitoring. Rectal
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
Status epilepticus is defined as continuous seizure activity lasting more than 5 minutes or two or more seizures without full recovery between seizures. It is classified into different types and has different clinical stages. Initial treatment involves benzodiazepines like lorazepam, diazepam, or midazolam. For refractory status epilepticus, additional anticonvulsants like fosphenytoin, valproate, or phenobarbital are used. If seizures continue, anesthetic agents like propofol, midazolam, or pentobarbitone are utilized to induce a burst suppression pattern on EEG for 12-24 hours.
The document defines status epilepticus and discusses its treatment. Status epilepticus is traditionally defined as continuous seizure activity lasting over 30 minutes, but the working definition is now 5 minutes to minimize risk. Treatment involves initial stabilization, then 1) benzodiazepines like lorazepam or diazepam, 2) second line drugs like fosphenytoin or valproic acid, and 3) third line anesthetic drugs like midazolam or pentobarbital via infusion if seizures remain uncontrolled. Mechanical ventilation may be needed for airway protection or raised intracranial pressure. The goal is to rapidly control seizures while monitoring for complications.
Status epilepticus (SE) is defined as a seizure lasting more than 30 minutes or recurrent seizures without regaining consciousness between seizures. SE is a medical emergency that requires rapid treatment to prevent neurological complications. The first line treatment for SE is a benzodiazepine like lorazepam or diazepam administered intravenously. If seizures continue after 10 minutes, a second antiseizure drug such as levetiracetam, fosphenytoin, or valproate is given. For refractory SE that persists despite two medications, a continuous infusion of midazolam, propofol, or pentobarbital is started.
Status epilepticus is defined as continuous seizure activity or intermittent seizures without full recovery between seizures. It can be convulsive or non-convulsive. Initial treatment involves stabilizing the airway, breathing, and circulation, followed by benzodiazepines like lorazepam or diazepam to stop seizures. If seizures continue, second line drugs like fosphenytoin or levetiracetam are used. For refractory cases, continuous infusions of midazolam, pentobarbital or propofol may be needed. The most common adverse effect is respiratory depression, so patients require monitoring. No significant difference in effectiveness exists between lorazepam and diazepam as initial
- 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
This document provides information on the definition, classification, treatment guidelines, and management of status epilepticus. It defines status epilepticus as generalized tonic-clonic seizures lasting more than 5 minutes or focal seizures with impaired awareness lasting over 10 minutes. It classifies different types of refractory and super-refractory status epilepticus. It discusses guidelines from medical organizations on treatment. It provides details on first-line and second-line anti-seizure medications for status epilepticus, including benzodiazepines like lorazepam and midazolam, as well as levetiracetam, valproate, fosphenytoin/phenytoin, phenobarb
This document summarizes guidelines from the American Epilepsy Society and Indian Pediatrics for the treatment of status epilepticus in children and adults. It defines status epilepticus and evaluates questions around effective initial and subsequent anticonvulsant therapies. For initial treatment, lorazepam, diazepam, and midazolam are recommended benzodiazepines, with midazolam preferred without IV access. Phenytoin or fosphenytoin are suggested as second line therapies. The treatment success rates decline with each subsequent therapy, and refractory cases may require anesthetic doses of midazolam, pentobarbital, propofol or thiopental with EEG monitoring. Rectal
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
Status epilepticus is defined as continuous seizure activity lasting more than 5 minutes or two or more seizures without full recovery between seizures. It is classified into different types and has different clinical stages. Initial treatment involves benzodiazepines like lorazepam, diazepam, or midazolam. For refractory status epilepticus, additional anticonvulsants like fosphenytoin, valproate, or phenobarbital are used. If seizures continue, anesthetic agents like propofol, midazolam, or pentobarbitone are utilized to induce a burst suppression pattern on EEG for 12-24 hours.
The document defines status epilepticus and discusses its treatment. Status epilepticus is traditionally defined as continuous seizure activity lasting over 30 minutes, but the working definition is now 5 minutes to minimize risk. Treatment involves initial stabilization, then 1) benzodiazepines like lorazepam or diazepam, 2) second line drugs like fosphenytoin or valproic acid, and 3) third line anesthetic drugs like midazolam or pentobarbital via infusion if seizures remain uncontrolled. Mechanical ventilation may be needed for airway protection or raised intracranial pressure. The goal is to rapidly control seizures while monitoring for complications.
Status epilepticus (SE) is defined as a seizure lasting more than 30 minutes or recurrent seizures without regaining consciousness between seizures. SE is a medical emergency that requires rapid treatment to prevent neurological complications. The first line treatment for SE is a benzodiazepine like lorazepam or diazepam administered intravenously. If seizures continue after 10 minutes, a second antiseizure drug such as levetiracetam, fosphenytoin, or valproate is given. For refractory SE that persists despite two medications, a continuous infusion of midazolam, propofol, or pentobarbital is started.
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
1) Chemotherapy induced nausea and vomiting is a serious side effect that can negatively impact quality of life. The mechanisms involve the central nervous system including brainstem areas that control vomiting.
2) Antiemetic treatments target neurotransmitters like serotonin, substance P, and dopamine to prevent nausea and vomiting. Combination regimens are most effective depending on the emetogenicity of the chemotherapy.
3) Studies show the addition of newer drugs like NK1 receptor antagonists, olanzapine, and palonosetron to standard treatments improves control of both acute and delayed nausea and vomiting from chemotherapy.
The document discusses refractory status epilepticus (RSE), which is status epilepticus that continues or recurs after treatment with anesthetic drugs. Nearly 40% of status epilepticus cases are refractory. RSE has a high mortality rate that is three times that of non-refractory status epilepticus. The main treatments for RSE are midazolam, propofol, and pentobarbital, which act as GABA agonists and some have additional mechanisms. Treatment is initiated with intravenous loading doses followed by continuous infusions titrated based on EEG monitoring to control seizures.
Intravenous Anaesthetics are a group of fast-acting
compounds that are used to induce a state of impaired
awareness of complete sedation.
These are drugs that, when given intravenously in an
appropriate dose, cause a rapid loss of consciousness.
1. Status epilepticus is defined as a seizure lasting more than 5 minutes or recurrent seizures without recovery in between.
2. It can be generalized convulsive seizures or non-convulsive without motor symptoms but ongoing EEG seizure activity.
3. Treatment involves stabilizing the patient, identifying and treating the underlying cause, giving benzodiazepines as first line, then fosphenytoin, phenytoin, phenobarbital or levetiracetam if still seizing, with escalation to anesthetic drugs, coma or general anesthesia if refractory.
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.
Antiepileptic drugs (AEDs) are used to treat epilepsy by decreasing the frequency and severity of seizures. The goal of AED treatment is to maximize quality of life by minimizing seizures and adverse drug effects. Most AEDs work by modifying ion conductance in neurons, prolonging sodium channel inactivation, inhibiting calcium currents, or enhancing inhibitory GABA transmission. AEDs are classified based on their mechanisms of action and pharmacokinetic properties. Choosing an appropriate AED depends on the seizure type and individual patient factors. Nursing considerations for AED administration include monitoring for side effects, ensuring compliance, advising against driving, and following up with patients.
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
- Status epilepticus and neonatal seizures require immediate evaluation and treatment in the ED, while other seizures in otherwise healthy children may not require a full evaluation.
- Seizures are classified as focal or generalized, and status epilepticus is defined as a prolonged seizure or recurrent seizures lasting over 5 minutes without consciousness returning.
- Evaluation of seizures includes bedside glucose, electrolytes, imaging if indicated by history, and EEG for refractory or prolonged seizures. Treatment involves benzodiazepines for active seizures, followed by antiepileptic drugs if needed.
This study compared the efficacy and safety of levetiracetam versus phenobarbital as first-line treatment for neonatal seizures. Levetiracetam achieved seizure freedom for 24 hours in 61% of infants compared to 42% for phenobarbital. Levetiracetam was also associated with fewer adverse effects such as sedation, respiratory suppression, and hypotension compared to phenobarbital. This randomized controlled trial provides evidence that levetiracetam is more effective and safer than phenobarbital for terminating neonatal seizures.
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.
1. The document discusses emerging drugs for the treatment of epilepsy, providing details on mechanisms of action, pharmacokinetics, clinical trials and adverse effects for several promising new anti-epileptic drugs.
2. These include brivaracetam, carisbamate, eslicarbazepine acetate, retigabine, perampanel, ganaxolone, and stiripentol. Drugs like brivaracetam and carisbamate are in Phase III trials as adjunctive therapies for partial onset seizures.
3. The newer drugs offer advantages over older anti-epileptics like fewer drug interactions and less toxicity profiles. They expand treatment options for
Status epilepticus is a medical emergency that requires prompt treatment to reduce mortality and morbidity. It is defined as continuous seizures for more than 5 minutes or two or more seizures without full recovery of consciousness between seizures. The longer seizures continue, the harder they are to stop and the higher the risks of permanent neurological damage and death. Treatment involves stabilizing the patient, administering rapid-acting benzodiazepines like lorazepam followed by long-acting anticonvulsants like fosphenytoin, phenobarbital, or phenytoin. If seizures continue, further doses of anticonvulsants or anesthetic medications may be needed. Prompt diagnosis and treatment are essential to minimize risks
starting and continuing treatment in epilepsysankalpgmc8
This document provides information on starting and continuing treatment for epilepsy. Some key points:
- About 10 million people in India have epilepsy, which is characterized by recurrent unprovoked seizures. Treatment can help 70-80% of people lead normal lives, but 50-70% currently receive no treatment or inadequate treatment.
- Diagnosis involves a detailed history, examination, and may include EEG, imaging studies, and video EEG. Treatment is usually started after a second unprovoked seizure and involves monotherapy with an antiepileptic drug like carbamazepine, valproate, or phenytoin.
- Follow-up care involves monitoring for seizure control and adverse effects. Treatment may need to
1. The patient, a 25-year-old woman, presented with her first unprovoked seizure and the doctor was deciding whether to start antiepileptic drug (AED) treatment.
2. Evidence shows that starting AED treatment after a first seizure reduces the risk of a second seizure occurring within two years compared to no treatment. However, the decision depends on factors like the patient's wishes.
3. The patient had another seizure after being discharged without AED treatment initially. The doctor decided to start her on lamotrigine and gradually increase the dose over several weeks.
4. Options for treatment if initial monotherapy fails include switching drugs, adding another AED, or alternative
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.
Status epilepticus is a medical emergency defined as continuous seizure activity lasting more than 5 minutes or recurrent seizures without regaining consciousness. It has an incidence rate of 10-60 per 100,000 people and is most common in children under 5 years old. Causes include infections, brain injuries, genetic conditions, and noncompliance with anti-seizure medications. The pathophysiology involves excessive excitation and reduced inhibition in the brain. Treatment involves stabilizing the patient, identifying and treating the underlying cause, giving benzodiazepines and other anti-seizure medications, and controlling refractory cases in the ICU with anesthetic medications. Early intervention is important to prevent neurological damage from prolonged seizures.
Status epilepticus (SE) is defined as continuous seizure activity lasting more than 5 minutes or 2 or more seizures within 5 minutes without regaining consciousness. SE is a medical emergency that requires rapid stabilization, seizure termination through pharmacotherapy, and treatment of the underlying cause. First-line drugs for seizure termination include benzodiazepines, phenytoin, and valproate. For refractory SE that does not respond to initial treatment, additional options include midazolam infusion, barbiturates, propofol, ketamine, or inhaled anesthetics. Prolonged SE can cause complications and is associated with higher mortality and long-term neurological deficits.
This document provides information on the clinical presentation, investigation, and treatment of malaria. It discusses how malaria commonly presents with symptoms like fever, chills, sweats, and headaches. It also covers severe complicated malaria and its symptoms. For investigation, it recommends examining blood films under microscopy, using rapid diagnostic tests, and PCR. It provides treatment guidelines for uncomplicated and severe falciparum malaria, including recommended drugs and dosages. It also discusses specific treatment considerations for populations like pregnant women, those with hepatic or renal impairment, children, and prevention through chemoprophylaxis.
This document provides an overview of the evaluation and management of seizures. It discusses the prevalence and types of seizures, differential diagnosis, classification, assessment including history, physical exam, labs and imaging. Management of new onset seizures, abortive therapies like benzodiazepines, antiepileptic drugs, and refractory status epilepticus are covered. It emphasizes the importance of rapid treatment since time to treatment affects response, and simplifying the approach with a standardized status epilepticus management algorithm.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
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
1) Chemotherapy induced nausea and vomiting is a serious side effect that can negatively impact quality of life. The mechanisms involve the central nervous system including brainstem areas that control vomiting.
2) Antiemetic treatments target neurotransmitters like serotonin, substance P, and dopamine to prevent nausea and vomiting. Combination regimens are most effective depending on the emetogenicity of the chemotherapy.
3) Studies show the addition of newer drugs like NK1 receptor antagonists, olanzapine, and palonosetron to standard treatments improves control of both acute and delayed nausea and vomiting from chemotherapy.
The document discusses refractory status epilepticus (RSE), which is status epilepticus that continues or recurs after treatment with anesthetic drugs. Nearly 40% of status epilepticus cases are refractory. RSE has a high mortality rate that is three times that of non-refractory status epilepticus. The main treatments for RSE are midazolam, propofol, and pentobarbital, which act as GABA agonists and some have additional mechanisms. Treatment is initiated with intravenous loading doses followed by continuous infusions titrated based on EEG monitoring to control seizures.
Intravenous Anaesthetics are a group of fast-acting
compounds that are used to induce a state of impaired
awareness of complete sedation.
These are drugs that, when given intravenously in an
appropriate dose, cause a rapid loss of consciousness.
1. Status epilepticus is defined as a seizure lasting more than 5 minutes or recurrent seizures without recovery in between.
2. It can be generalized convulsive seizures or non-convulsive without motor symptoms but ongoing EEG seizure activity.
3. Treatment involves stabilizing the patient, identifying and treating the underlying cause, giving benzodiazepines as first line, then fosphenytoin, phenytoin, phenobarbital or levetiracetam if still seizing, with escalation to anesthetic drugs, coma or general anesthesia if refractory.
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.
Antiepileptic drugs (AEDs) are used to treat epilepsy by decreasing the frequency and severity of seizures. The goal of AED treatment is to maximize quality of life by minimizing seizures and adverse drug effects. Most AEDs work by modifying ion conductance in neurons, prolonging sodium channel inactivation, inhibiting calcium currents, or enhancing inhibitory GABA transmission. AEDs are classified based on their mechanisms of action and pharmacokinetic properties. Choosing an appropriate AED depends on the seizure type and individual patient factors. Nursing considerations for AED administration include monitoring for side effects, ensuring compliance, advising against driving, and following up with patients.
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
- Status epilepticus and neonatal seizures require immediate evaluation and treatment in the ED, while other seizures in otherwise healthy children may not require a full evaluation.
- Seizures are classified as focal or generalized, and status epilepticus is defined as a prolonged seizure or recurrent seizures lasting over 5 minutes without consciousness returning.
- Evaluation of seizures includes bedside glucose, electrolytes, imaging if indicated by history, and EEG for refractory or prolonged seizures. Treatment involves benzodiazepines for active seizures, followed by antiepileptic drugs if needed.
This study compared the efficacy and safety of levetiracetam versus phenobarbital as first-line treatment for neonatal seizures. Levetiracetam achieved seizure freedom for 24 hours in 61% of infants compared to 42% for phenobarbital. Levetiracetam was also associated with fewer adverse effects such as sedation, respiratory suppression, and hypotension compared to phenobarbital. This randomized controlled trial provides evidence that levetiracetam is more effective and safer than phenobarbital for terminating neonatal seizures.
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.
1. The document discusses emerging drugs for the treatment of epilepsy, providing details on mechanisms of action, pharmacokinetics, clinical trials and adverse effects for several promising new anti-epileptic drugs.
2. These include brivaracetam, carisbamate, eslicarbazepine acetate, retigabine, perampanel, ganaxolone, and stiripentol. Drugs like brivaracetam and carisbamate are in Phase III trials as adjunctive therapies for partial onset seizures.
3. The newer drugs offer advantages over older anti-epileptics like fewer drug interactions and less toxicity profiles. They expand treatment options for
Status epilepticus is a medical emergency that requires prompt treatment to reduce mortality and morbidity. It is defined as continuous seizures for more than 5 minutes or two or more seizures without full recovery of consciousness between seizures. The longer seizures continue, the harder they are to stop and the higher the risks of permanent neurological damage and death. Treatment involves stabilizing the patient, administering rapid-acting benzodiazepines like lorazepam followed by long-acting anticonvulsants like fosphenytoin, phenobarbital, or phenytoin. If seizures continue, further doses of anticonvulsants or anesthetic medications may be needed. Prompt diagnosis and treatment are essential to minimize risks
starting and continuing treatment in epilepsysankalpgmc8
This document provides information on starting and continuing treatment for epilepsy. Some key points:
- About 10 million people in India have epilepsy, which is characterized by recurrent unprovoked seizures. Treatment can help 70-80% of people lead normal lives, but 50-70% currently receive no treatment or inadequate treatment.
- Diagnosis involves a detailed history, examination, and may include EEG, imaging studies, and video EEG. Treatment is usually started after a second unprovoked seizure and involves monotherapy with an antiepileptic drug like carbamazepine, valproate, or phenytoin.
- Follow-up care involves monitoring for seizure control and adverse effects. Treatment may need to
1. The patient, a 25-year-old woman, presented with her first unprovoked seizure and the doctor was deciding whether to start antiepileptic drug (AED) treatment.
2. Evidence shows that starting AED treatment after a first seizure reduces the risk of a second seizure occurring within two years compared to no treatment. However, the decision depends on factors like the patient's wishes.
3. The patient had another seizure after being discharged without AED treatment initially. The doctor decided to start her on lamotrigine and gradually increase the dose over several weeks.
4. Options for treatment if initial monotherapy fails include switching drugs, adding another AED, or alternative
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.
Status epilepticus is a medical emergency defined as continuous seizure activity lasting more than 5 minutes or recurrent seizures without regaining consciousness. It has an incidence rate of 10-60 per 100,000 people and is most common in children under 5 years old. Causes include infections, brain injuries, genetic conditions, and noncompliance with anti-seizure medications. The pathophysiology involves excessive excitation and reduced inhibition in the brain. Treatment involves stabilizing the patient, identifying and treating the underlying cause, giving benzodiazepines and other anti-seizure medications, and controlling refractory cases in the ICU with anesthetic medications. Early intervention is important to prevent neurological damage from prolonged seizures.
Status epilepticus (SE) is defined as continuous seizure activity lasting more than 5 minutes or 2 or more seizures within 5 minutes without regaining consciousness. SE is a medical emergency that requires rapid stabilization, seizure termination through pharmacotherapy, and treatment of the underlying cause. First-line drugs for seizure termination include benzodiazepines, phenytoin, and valproate. For refractory SE that does not respond to initial treatment, additional options include midazolam infusion, barbiturates, propofol, ketamine, or inhaled anesthetics. Prolonged SE can cause complications and is associated with higher mortality and long-term neurological deficits.
This document provides information on the clinical presentation, investigation, and treatment of malaria. It discusses how malaria commonly presents with symptoms like fever, chills, sweats, and headaches. It also covers severe complicated malaria and its symptoms. For investigation, it recommends examining blood films under microscopy, using rapid diagnostic tests, and PCR. It provides treatment guidelines for uncomplicated and severe falciparum malaria, including recommended drugs and dosages. It also discusses specific treatment considerations for populations like pregnant women, those with hepatic or renal impairment, children, and prevention through chemoprophylaxis.
This document provides an overview of the evaluation and management of seizures. It discusses the prevalence and types of seizures, differential diagnosis, classification, assessment including history, physical exam, labs and imaging. Management of new onset seizures, abortive therapies like benzodiazepines, antiepileptic drugs, and refractory status epilepticus are covered. It emphasizes the importance of rapid treatment since time to treatment affects response, and simplifying the approach with a standardized status epilepticus management algorithm.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
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.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
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
4. Pathophysiology of SE – in a nutshell
• GABA A receptor internalisation
• NMDA receptor increased expression
• AMPA receptors lose their GLUA 2 subunit
• Potassium-chloride transporter KCC2 phosphorylation and its consequent
internalisation
• Presynaptic adenosine A1 receptor is decreased
• Presynaptic GABA(B) receptor expression is decreased
• Increase in Substance P
• Decrease in Neuro-peptide Y
• Decrease in other inhibitory Neuro-peptides like Galanin, Dynorphin, Somatostatin
6. Introduction
• Management of status epilepticus requires parallel work on different domains
• Standardized information transfer from EMS to the emergency department team
• Acute stabilization and monitoring of vital signs
• Rapid identification of etiologies with independently essential acute treatment
• Start of status epilepticus treatment
9. 0 to 5 minutes : Stabilisation Phase
• Maintain patent airway during all stages of management of SE.
• Clear the oral secretions (mouth, followed by nose)
• Keeping in recovery position is advisable to prevent aspiration
• Immobilize cervical spine IF trauma is suspected
• Oral airway : prevent tongue from falling back
• Consider endotracheal intubation if airway is not maintainable with above
measures
10. 0 to 5 minutes : Stabilisation Phase
• All Pt’s with SE should :
• Have their breathing and spo2 monitored continuously.
• Be given supplemental oxygen
• Depending on the degree of altered sensorium and duration of SE maintain
oxygen saturation by:
• Supplemental oxygen,
• AMBU bag,
• Non-invasive continuous positive airway pressure (CPAP) and
• Invasive ventilation by endotracheal intubation.
11. 0 to 5 minutes : Stabilisation Phase
• Hypoxemia may result from :
• Respiratory depression
• Apnea
• Aspiration
• Airway obstruction and
• Neurogenic pulmonary edema
Wijdicks E. Neurologic catastrophies in the emergency department. Boston: Butterworth-Heinemann
14. • “All children with ongoing seizures should be given supplemental
oxygen to ameliorate cerebral hypoxia, as it has been seen that
the degree of hypoxia is often underestimated”
15. • Other guidelines advocating oxygen supplementation during status epilepticus:
• U.K’s NICE guidelines
• AAN-in it’s Continuum publication
• PALS algorithm
16.
17. 0 to 5 minutes : Stabilisation Phase
• Place continuous cardiorespiratory monitors and pulse oximetry
• Establish IV or IO access at least two lines
• Draw samples for the following laboratory studies :
• Serum electrolytes, including Ca, Mg
• Glucose,
• LFTs,
• CBC,
• Toxicology and
• ASM levels
18. 0 to 5 minutes : Stabilisation Phase
• Check finger stick blood glucose. If glucose < 60 mg/dl then
• Adults: 100 mg Thiamine IV then 50 ml D50W IV
• Children > 2 years: 2 ml/kg D25W IV
• Children < 2 years: 4 ml/kg D12.5W IV
19. 0 to 5 minutes : Stabilisation Phase
Properly managed stabilisation phase will :
• Prevent Respiratory failure
• Major complication
• 80% of patients with generalized SE
• Independent predictor of death
• Identify and treat potential underlying causes
• Hypoglycemia
• Metabolic abnormalites
• Fever/infection
23. 5-20 minutes: Initial Therapy Phase
• Nine RCTs addressed the efficacy of initial therapy
• Three class I
• One class II and
• Five class III
• The following are the class I trials :
• 1998 - Veteran’s Affairs status epilepticus study
• 2001 - Comparison of Lorazepam, Diazepam, and Placebo for the Treatment of Out-of-Hospital
Status Epilepticus [NEJM]
• 2012 - RAMPART trial
26. • Randomized, double-blind trial
• To evaluate IV benzodiazepines administered by paramedics for the
treatment of out-of-hospital status epilepticus
• Intravenous diazepam (5 mg), lorazepam (2 mg), or placebo
• An identical second injection was given if needed
27. • Status epilepticus had been terminated on arrival at E.D in :
• 59.1 percent in Lorazepam group
• 42.6 percent in Diazepam group
• 21.1 percent in Placebo group
• (P=0.001)
• Out-of-hospital complication (hypotension, cardiac dysrhythmia, or respiratory
intervention) occurred in :
• 10.6 percent in Lorazepam group
• 10.3 percent in Diazepam group
• 22.5 percent in Placebo group
28. • RAMPART (Rapid Anti-convulsant Medication Prior To Arrival) trial (NEJM
2012)
• Double-blind, randomized, noninferiority trial
• Comparison of efficacy of IM midazolam with that of IV Lorazepam
• Children and adults in status epilepticus treated by paramedics
• Primary outcome: Absence of seizures at the time of arrival in the
emergency department without the need for rescue therapy
29. • Dosage:
• Adults and children with an estimated body weight of more than 40 kg:
• 10 mg of IM Midazolam followed by IV placebo [or] IM placebo followed
by 4 mg of IV Lorazepam.
• In children with an estimated weight of 13 to 40 kg :
• 5 mg of IM Midazolam or 2 mg of IV Lorazepam.
30. • At the time of arrival in the ED, seizures were absent without rescue
therapy in :
• 329 of 448 subjects (73.4%) in the intramuscular-midazolam group
• 282 of 445 (63.4%) in the intravenous-lorazepam group
• (absolute difference, 10 percentage points; 95% confidence interval, 4.0 to
16.1; P<0.001 for both noninferiority and superiority).
31. 5-20 minutes: Initial Therapy Phase
• Midazolam
• Water-soluble benzodiazepine
• Can be administered by different routes: IV, IM, buccal, and intranasal.
• Ideally suited for early out-of-hospital treatment by caregivers or paramedics
• Non-IV Midazolam by any route VS Diazepam by any route :
• For seizure cessation both groups are equally efficacious
• Time interval btw arrival & seizure cessation was significantly shorter in Midazolam group
• No difference in adverse effects was found between the two groups
32. • Buccal Midazolam was more effective than rectal diazepam in terminating status
epilepticus
• Out-of-hospital status epilepticus : Buccal or intranasal midazolam can be
regarded as the first-choice treatment
• First-line Non-IV treatment will NOT stop status epilepticus in around 20% to 30%
of cases
Brigo F, Nardone R, Tezzon F, Trinka E. Nonintravenous midazolam versus intravenous or rectal diazepam for
the treatment of early status epilepticus: a systematic review with meta- analysis. Epilepsy Behav 2015;49:
5-20 minutes: Initial Therapy Phase
35. 5-20 minutes: Initial Therapy Phase
• Current guidelines recommended dose for initial buccal or intranasal route :
• 0.3 mg/kg to a maximum of 10 mg
• Dose can be divided and given half in each nostril
• Absorption takes approximately 1–3 minutes
• The efficacy of the alternative routes of midazolam administration was
• 79% for the intranasal route
• 82–100% for intramuscular route
36. • Phenobarbitone :
• Enhances γ-aminobutyric acid (GABA) inhibition.
• One of the oldest drugs used to treat SE
• Efficacy has been demonstrated for both early and established SE.
• However, the unfavourable safety profile of phenobarbital restricts its use
• Respiratory depression,
• Hypotension, and
• Sedation.
• IV loading dose of phenobarbital : 10–20 mg/kg.
• The infusion rate should not exceed :
• 100 mg/min in adults and
• 2 mg/kg/min in children.
5-20 minutes: Initial Therapy Phase
37. Veteran Affairs SE Co-opearive Study Group trial
Veteran Affairs SE Coopearive Study Group trial
Phenobarbital (15 mg/kg) vs Lorazepam (0.1 mg/kg) as a first-line treatment
Lorazepam is no more efficacious than phenobarbital
38. 5-20 minutes: Initial Therapy Phase
• Should begin when the seizure duration reaches 5 minutes
• Should conclude by the 20-minute mark when response (or lack of response)
• A benzodiazepine is recommended as the initial therapy of choice, given their
demonstrated efficacy, safety, and tolerability
• Although IV phenobarbital is established as efficacious and well tolerated as
initial therapy (level A, 1 class I RCT), its slower rate of administration, positions it
as an alternative initial therapy rather than a drug of first choice.
39. 5-20 minutes: Initial Therapy Phase
• Key points to remember :
• Initial therapy should be administered as an adequate single full dose rather than
broken into multiple smaller doses.
• Initial therapies should not be given twice except for IV lorazepam and diazepam
that can be repeated at full doses once (level A, two class I, one class II RCT).
• Doses listed in the initial therapy phase are those used in class I trials.
43. 20-40 minutes: Second Therapy Phase
• Second therapy phase (20-40 minutes of seizure activity) begins
when response (or lack of response) to the initial therapy becomes
apparent.
• Reasonable options include :
• Fosphenytoin,
• Valproic acid,
• Levetiracetam.
44. ESETT trial
• Established Status Epilepticus Treatment Trial (ESETT) trial
• 384 pediatric and adult patients with convulsive status epilepticus
• Refractory to Benzodiazepines
• Compared Fos-Phenytoin, Valproic acid and Levetiracetam
• Found that all 3 are equally effective and have similar rates of adverse effects
• High-quality evidence
• Choose one among them according to patient baseline characteristics
45.
46. FOSPHENYTOIN
• Fosphenytoin :
• Pro-drug of Phenytoin
• Hydrolyzed to phenytoin by serum phosphatases.
• highly water soluble - unlikely to precipitate during IV administration.
• Risk of local irritation at the site of infusion is significantly less compared to phenytoin
• Infused much more rapidly (up to 150 mg PE/min vs 50 mg/min with phenytoin).
• IM administration possible if IV access cannot be obtained due to it’s water solubility
47. FOSPHENYTOIN
• Fosphenytoin :
• It is the preferred formulation of phenytoin for rapid intravenous dosing.
• The loading dose is 20 mg PE/kg (Max 1500 PE/dose)
• Infused at a rate of 100 to 150 mg PE/minute.
• Cardiac monitoring is required during the infusion of Fosphenytoin or Phenytoin
• Cardiac monitoring should be continued for at least 15 minutes after the end of a
Fosphenytoin infusion,
(while it continues to be dephosphorylated into phenytoin)
49. PHENYTOIN
• Phenytoin is generally started with a loading dose of 20 mg/kg (max 1500mg)
• Infused at a rate of up to 50 mg/minute
• Modify the infusion rate if hypotension or adverse cardiovascular events occur.
• Risk increase with higher infusion rates, due to the propylene glycol
(used to solubilize phenytoin)
• Local pain and injury (including venous thrombosis and the rare purple glove syndrome)
increase with more rapid infusions.
• Risk of cardiac arrhythmias – Hence cardiac monitoring during infusion is mandatory
50. SODIUM VALPROATE
• Loading dose of 40 mg/kg (Maximum dose 3000 mg)
• Infused at a rate of 10 mg/kg per minute in adults
• Full dose can be given in four minutes, with no significant risk of acute adverse effects
• Loading doses in this range yield :
• concentrations in therapeutic ranges without significant sedation
51. SODIUM VALPROATE
• Preferred over phenytoin in patients with primary generalized epilepsies
• Particularly useful in patients with focal or myoclonic status epilepticus (MSE)
• Patients who are on enzyme-inducing ASM’s may need higher maintenance doses or
shorter intervals between doses
• Free phenytoin level often rises markedly with concurrent administration, as both
agents are highly protein-bound
52. Sodium Valproate
• Risk of hepatic toxicity and hyperammonemic encephalopathy
• Particularly in children with Mitochondrial disorders & some Aminoacidopathies
• Risks of hepatic dysfunction and coagulopathy are important considerations
53. LEVETIRACETAM
• Levetiracetam :
• Loading dose of 60 mg/kg IV in adults (maximum 4500 mg)
• Infused over 5 to 15 minutes.
• Doses are typically infused over 15 minutes.
• Retrospective data suggest that rapid intravenous infusion (over 5 minutes) of
levetiracetam in doses up to 4500 mg is safe and well-tolerated
54. LACOSAMIDE
• IV Lacosamide (200 to 400 mg IV bolus) is usually well tolerated
• May have similar efficacy compared with other agents used to treat refractory status
epilepticus
• Rare serious adverse events include second-degree and complete atrioventricular block
• ECG monitoring before and during maintenance period to look for PR prolongation.
• Comorbid heart disease and with concurrent use of other drugs that may prolong the
PR interval – Additional caution required
55. PHENOBARBITONE
• Very effective antiseizure medication,
• Especially in the acute management of seizures,
• High doses of phenobarbital will control almost any seizure
• But at the cost of substantial sedation and potential reduction of blood pressure and
respiration
56. PHENOBARBITONE
• Initial doses of 20 mg/kg infused at a rate of 30 to 50 mg/minute are generally used
• Slower infusion rates should be used in older adult patients
• Careful monitoring of respiratory and cardiac status is mandatory.
• Intubation is often necessary.
• The risk of prolonged sedation with phenobarbital is greater
• Half-life of 87 to 100 hours.
59. Treatment failure causes
• Inadequate drug treatment
• Failure to initiate or continue maintenance antiepileptic drug
therapy
• Medical factors can exacerbate seizures
• Failure to treat (or identify) the underlying cause
• Misdiagnosis : pseudo-status epilepticus.
60. • Wilson Disease patients , INH toxicity : Pyridoxine supplementation
• Porphyrias : Use non enzyme inducing ASMs like LEV.
• Coexisting liver disease : Avoid VPA. LEV is best
• Coexisting kidney disease : LEV is best avoided. Or titrate according
to EFR
63. • Randomised controlled prospective study conducted on 150 patients
• To compare the efficacy of phenytoin (n=50), valproate (n=50) and levetiracetam (n=50) along with lorazepam in patients with GCSE.
• All recruited patients received IV lorazepam (0.1mg/kg) followed by one of the 3 AEDs viz. phenytoin (20 mg/kg), valproate (30
mg/kg), Levetiracetam (25 mg/kg).
• Those who remained uncontrolled with 1st AED, received other two AEDs sequentially.
• RESULTS:
• Phenytoin, valproate, and levetiracetam are safe and equally efficacious following lorazepam in GCSE.
• The choice of AEDs could be individualised based on co- morbidities.
• SE could be controlled in 92% of patients with AEDs only and anaesthetics were not required in them
68. Midazolam
• Mechanism of action :
• GABA agonist.
• Dose and administration :
• Bolus: 0.2 mg/kg (0.1 to 0.3mg/kg)
• Continuous infusion: 0.05 – 0.5mg/kg/hr.
• Increase infusion rate by 0.05 mg/kg every 3 hours
• Target :
• To maintain a seizure-free state (or) Burst suppression pattern (5 to 15-second inter-burst interval)
on continuous EEG monitoring
• Maintain midazolam infusion for 24 hr seizure-free period
69. Midazolam
• Side effects : Respiratory depression, hypotension, sedation.
• When used as an infusion:
• Withdrawal syndrome,
• Delirium,
• Tachyphylaxis after 72 hours,
• Respiratory and cough reflex suppression,
• Metabolites accumulation post prolonged infusion.
70. Midazolam
• Very high dose midazolam infusion :
• Non-anion gap hyperchloremic metabolic acidosis
• Resolves once the infusion of midazolam is discontinued.
• Monitoring : Blood gases with continuous infusion
71. Propofol
• NMDA antagonist
• Positively modulates the inhibitory function of the GABA
• Dose and administration :
• 1-2mg/kg bolus administered by IV infusion over approximately five minutes
• Repeated (0.5 to 2 mg/kg) until seizures stop, up to a maximum total dose of 10 mg/kg.
• Start continuous infusion at 1 mg/kg per hour and increase infusion rate (steps of 0.5 mg/kg/hr
every 10 minutes) up to 5mg/kg/hr.
• Target :
• To maintain a seizure-free state or
• Burst suppression pattern on continuous electroencephalogram monitoring
72. Propofol
• Common Side effects of Propofol :
Bradycardia,
Hypotension,
Apnoea,
Arrythmia,
Thrombosis,
Phlebitis,
Deranged liver function tests (particularly transaminases),
Pancreatitis.
73. Propofol
• Propofol Infusion Syndrome (PRIS) : Rare but dangerous adverse effect
• Lactic acidosis,
• Hyperkalaemia,
• Hyperlipidaemia,
• Cardiac dysfunction,
• Rhabdomyolysis,
• Renal failure
• Risk factors for propofol infusion syndrome include :
• Young age (Usually avoided in children)
• Carbohydrate depletion,
• Concomitant use of corticosteroids, and
• Prolonged infusion at high doses
( for longer than 48 h at dosages exceeding 5 mg/kg/h)
74. Propofol
• Monitoring :
• Creatine Kinase (CK) levels should be monitored daily in patients on Propofol.
• Liver function
• Reliable indicator for the development of PRIS :
• Rising CK levels + Acidosis + Increasing lactate levels
• If indicative of PRIS: Consider to stop or reduce the dose of propofol
75. KETAMINE
• NMDA receptor antagonist.
• Dose and administration
• Loading dose of ketamine is 0.5-2 mg/kg, followed by an infusion of 1 to 10
mg/kg per hour
• Titrated to suppression of electrographic seizures or Burst suppression pattern
for 24-48 hrs
• Contraindications
• Patients with severe coronary or myocardial disease or cerebrovascular
accident
76. KETAMINE
• Neuroprotectant against glutamate-induced widespread neuronal necrosis.
• It interacts with opioid, monoaminergic, muscarinic, and nicotinic receptor ion channels and
modulates some cytokines.
• It may reduce the neuroinflammation, which may contribute to the refractoriness of SE
• Fujikawa recommends early initiation of ketamine in Refractory SE
• Fujikawa DG. Starting ketamine for neuroprotection earlier than its current use as an anesthetic/antiepileptic drug late in refractory status epilepticus. Epilepsia.
2019; 60(5):373–380
77. KETAMINE
• Cautions
• Hepatic impairment – metabolised in the liver CYP 450, action may be prolonged in patients
with impaired liver function
• Acute intermittent porphyria
• Psychiatric illness – confusion, agitation, hallucinations – specially during weaning
• Conditions where an elevated ICP or IOP may be detrimental
• Cardiac disease – increases myocardial oxygen consumption
• Deranged liver function tests (when used for >3days)
• Rash
78. KETAMINE
• Midazolam + Ketamine combination :
• Different MOA , hence synergistic effect
• Hypotention + Hypertention
• Neuroprotective effect
• Relative ease of availability and administration
79. Thiopentone sodium
• Thiopental, its first metabolite pentobarbital :
• are the oldest compounds used in the setting of RSE
• In addition to GABAA modulation, barbiturates have an NMDA-antagonist action in vitro
• tendency to accumulate in adipose tissue.
• They have a long half-life (up to 36 h) after continuous administration
• Thiopental Dosage:
• Started with a bolus of 3–5 mg/kg,
• Then further boluses of 1–2 mg/kg every 2–3 min (until seizures are controlled )
• Then continuous infusion at a rate of 3–7 mg/kg/h
80. Thiopentone sodium
• Problematic pharmacokinetics
• Zero order kinetics
• Profound tendency to accumulate
• Auto-induction
• Drug-drug interactions
• Long recovery time
• Hypotension
• Hypothermia
• Cardio-respiratory depression
• Pancreatic and Hepatic toxicity
82. Points to remember during IV anesthetics treatment in RSE
• Reverse anaesthesia after 24–48h
• If seizures continue, then to re-establish anaesthesia (cycling).
• Such cycles should be repeated several times.
• If the status continues to recur, the duration of individual cycles can be increased,
and anaesthesia continued for up to 5 days at a time.
• The anaesthesia should be weaned slowly on reversal.
• Prolonged anaesthesia carries increasing iatrogenic risks
• Skilled ICU care and monitoring for complications is mandatory
Shorvon et al
83. EEG Target Pattern With IVGA
• Considerable controversy
• Some protocols aim for clinical or electrical suppression of seizure activity,
• Many treatment protocols call for titration to a burst-suppression pattern, and
• Still other protocols suggest that the EEG should be fully suppressed
(Isoelectric).
• Even when burst-suppression is the target there is little agreement as to what
constitutes an optimal burst-suppression pattern.
Burst durations of >10 s, 15–30 s, or 3–9 bursts per min.
84. • “ targeting EEG burst- suppression patterns with an inter-burst interval of about 10s for
24h,followed by progressive tapering over 6–12h under EEG control, seems to be a reasonable
option “
85. • Compared with seizure suppression without full EEG suppression (n = 59),
titration of treatment to EEG background suppression (n = 87) was associated
with :
• Lower frequency of breakthrough seizures (4 % vs 53%; p < 0.001)
• Higher frequency of hypotension (76% vs 29%; p < 0.001).
86.
87. • Current European Guidelines recommend anaesthetic drugs titration to :
• EEG burst-suppression for propofol and thiopental sodium,
• Seizure suppression for midazolam infusion.
• It is suggested that continuous infusions be maintained for at least 24 h at
these endpoints before weaning
88. Duration of Coma Before Reducing IV Anesthetics
• Another facet in the treatment of refractory SE with strong opinions but weak data.
• Recommendations regarding the duration of the initial period of induced coma vary
from 12 to 48 h.
• Holtkamp et al. surveyed 91 'opinion leaders' specializing in critical care neurology or
epileptology in three central European countries
• 22% : reduce drug dose within the first 24 hr
• 72% : reduce dose between 24 and 48 hr and
• 5% : reduce dose between 48 and 72 h.
90. Grey areas
• Oxygen administration ?
• Whether or not to give ASM in those patients who achieved seizure control with
benzodiazepines?
• Whether or not to repeat second line therapy at the end of 40 min ?
• EEG target after initiation of IV anesthetic agents ?
Limitations to the ESETT include a substantial rate (approximately 50 percent) of unblinding of investigators and clinicians to permit choosing a second antiseizure medication for ongoing seizures; inadvertent enrollment of patients without status epilepticus, including patients with psychogenic nonepileptic seizures (approximately 10 percent of the study population, likely unavoidable); capping of weight-based dosing at 75 kg (such that heavier patients received a lower mg/kg dose); and absence of confirmatory EEG.
Published in 2019
The only study that has attempted to compare the relative efficacy of burst-suppression versus full EEG suppression in the treatment of refractory SE is the Claassen et al. review of 193 cases of refractory SE discussed above.