Status epilepticus resident survival guide: Difference between revisions
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{{familytree | | | | | | | | | | | | | | | | | G01 | | | | | | | | | | | | | | | | | | | | | |G01='''Recurrent or ongoing seizure 30 mins after onset? (Emergency)''' <br><div style="float: left; text-align: left; line-height: 150% "> | {{familytree | | | | | | | | | | | | | | | | | G01 | | | | | | | | | | | | | | | | | | | | | |G01='''Recurrent or ongoing seizure 30 mins after onset? (Emergency)''' <br><div style="float: left; text-align: left; line-height: 150% "> | ||
'''Administer IV antiepileptic drugs:'''<br> | '''Administer IV antiepileptic drugs:<ref name="pmid16488380">{{cite journal| author=Chen JW, Wasterlain CG| title=Status epilepticus: pathophysiology and management in adults. | journal=Lancet Neurol | year= 2006 | volume= 5 | issue= 3 | pages= 246-56 | pmid=16488380 | doi=10.1016/S1474-4422(06)70374-X | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16488380 }} </ref>'''<br> | ||
❑ IV [[phenytoin]] ( | ❑ IV [[phenytoin]] ( 20-30 mg/kg), monitor ECG during the infusion<br> | ||
OR <br> | |||
❑ IV [[fosphenytoin]] ( 20-30 mg/kg), monitor ECG during the infusion<br> | |||
OR <br> | |||
❑ IV [[valproic acid]] ( 40-60 mg/kg, 3 mg/kg/min)</div>}} | |||
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{{familytree | | | | | | | | | | | | | | | | | I01 | | | | | | | | | | | | | | | | | | | | | |I01='''Ongoing seizure 60 mins after onset? (Emergency)'''<br><div style="float: left; text-align: left; line-height: 150% "> | {{familytree | | | | | | | | | | | | | | | | | I01 | | | | | | | | | | | | | | | | | | | | | |I01='''Ongoing seizure 60 mins after onset? (Emergency)'''<br><div style="float: left; text-align: left; line-height: 150% "> |
Revision as of 15:57, 19 December 2013
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]; Rim Halaby, M.D. [3]
Definition
Status epilepticus is defined as continuous clinical and/or electroencephalographic seizure persisting longer than 5 minutes or the occurrence of two or more episodes of seizures within one hour without returning to the baseline level of consciousness between the seizures.[1]
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Status epilepticus is a life threatening condition by itself because it results in serious immediate and long term morbidity and mortality if the convulsive seize is not terminated by 30 minutes; therefore, treatment is required urgently.
Common Causes
- Alcoholism
- Brain abscess
- Brain trauma
- Cardiac arrest
- Cerebrovascular disorders
- CNS tumor
- Drug toxicity
- Electrolytes abnormalities
- Encephalitis
- Hypertensive encephalopathy
- Hypoglycemia
- Hypoxia
- Low antiepileptic drug levels in patients with epilepsy
- Meningitis
- Sepsis
- Stroke
- Uremia
- Withdrawal from opioids, benzodiazepine, barbiturates or alcohol[2][1]
Management
Shown below is an algorithm summarizing the approach to status epilepticus. The goal of the treatment is to stop the seizure as soon as possible; therefore, begin the general measures and administer the antiepileptic medications (AED) SIMULTANEOUSLY.
Characterize the symptoms: ❑ Tonic phase with muscle spasms ❑ Rapid jerky movement ❑ Uprolling of eyes ❑ Tongue biting ❑ Incontinence Determine the onset of symptoms: ❑ Ask a witness | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
General measures to be done SIMULTANEOUSLY and in PARALLEL to the administration of antiepileptic medications (Emergency): Begin initial care: ❑ Turn patient to side ❑ Secure airway ❑ Assess respiratory and cardiac functions ❑ Administer high concentration O2 ❑ Maintain blood pressure ❑ Establish IV access ❑ Institute regular monitoring for pulse, blood pressure, temperature ❑ ECG monitoring ❑ Check fingerstick glucose, and correct hypoglycemia if present (Emergency) Order labs: Consider vitamin deficiencies: Consider alternative diagnosis: Treat acidosis if severe | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Begin treatment ASAP (Emergency): Administer benzodiazepines: Second line therapy: ❑ Buccal midazolam (10 mg) or rectal diazepam (10-20 mg) if IV access could not be established or IV lorazepam is not available | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Recurrent or ongoing seizure 30 mins after onset? (Emergency) Administer IV antiepileptic drugs:[3] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ongoing seizure 60 mins after onset? (Emergency) Elective coma induction with anesthestic agents:[4] Ensure full intensive care support: | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Adapted from the 2012 National Institute for Health and Care Excellence (NICE) clinical guidelines.
Do's
- Make sure to secure airway and maintain blood pressure within normal ranges, then administer anticonvulsants and then proceed to complete the diagnostic workup.[3]
- In the case of seizures lasting more than 5 minutes, it is beneficial do begin pre-hospital treatment with rectal diazepam among adults and children known to have frequent seizure episodes. Intravenous lorazepam or diazepam can be started by well-trained teams of paramedics during the pre-hospital care of patients with seizures lasting more than 5 minutes.[3]
- The initial treatment with benzodiazepines ( lorazepam, midazolam or diazepam) may be repeated once 10 minutes following the first administered dose.
Dont's
- Don't delay the initiation of treatment during the initial diagnostic evaluation.[3]
References
- ↑ 1.0 1.1 Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T; et al. (2012). "Guidelines for the evaluation and management of status epilepticus". Neurocrit Care. 17 (1): 3–23. doi:10.1007/s12028-012-9695-z. PMID 22528274.
- ↑ Trinka E, Höfler J, Zerbs A (2012). "Causes of status epilepticus". Epilepsia. 53 Suppl 4: 127–38. doi:10.1111/j.1528-1167.2012.03622.x. PMID 22946730.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Chen JW, Wasterlain CG (2006). "Status epilepticus: pathophysiology and management in adults". Lancet Neurol. 5 (3): 246–56. doi:10.1016/S1474-4422(06)70374-X. PMID 16488380.
- ↑ Rossetti AO, Lowenstein DH (2011). "Management of refractory status epilepticus in adults: still more questions than answers". Lancet Neurol. 10 (10): 922–30. doi:10.1016/S1474-4422(11)70187-9. PMC 3202016. PMID 21939901.
- ↑ Lowenstein DH, Alldredge BK (1998). "Status epilepticus". N Engl J Med. 338 (14): 970–6. doi:10.1056/NEJM199804023381407. PMID 9521986.