Status epilepticus resident survival guide: Difference between revisions
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==Management== | ==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.<br><br> | 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'''.<br><br> | ||
{{familytree/start |summary=Seizure Management.}} | {{familytree/start |summary=Seizure Management.}} | ||
{{familytree | | | | | | | | | | | | | | | | | A11 | | | | | | | | | | | | | | | | | | | | | |A11='''Characterize the symptoms:'''<br><div style="float: left; text-align: left; line-height: 150% "> ❑ Aura: altered vision and/or hearing and/or <br> ❑ Tonic phase with muscle spasms and/or <br> ❑ Rapid jerky movement and/or <br> ❑ Uprolling of eyes and/or <br> ❑ Tounge bite and/or <br> ❑ Incontinence </div>}} | {{familytree | | | | | | | | | | | | | | | | | A11 | | | | | | | | | | | | | | | | | | | | | |A11='''Characterize the symptoms:'''<br><div style="float: left; text-align: left; line-height: 150% "> ❑ Aura: altered vision and/or hearing and/or <br> ❑ Tonic phase with muscle spasms and/or <br> ❑ Rapid jerky movement and/or <br> ❑ Uprolling of eyes and/or <br> ❑ Tounge bite and/or <br> ❑ Incontinence </div>}} | ||
{{familytree | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | |B01='''General measures (Emergency):'''<br><div style="float: left; text-align: left; line-height: 150% "> '''Begin initial care:''' <br>❑ Turn patient to side <br> ❑ Secure airway<br> ❑ Assess respiratory and cardiac functions <br> ❑ Administer high concentration O<sub>2</sub> <br> ❑ Establish IV access<br> ❑ Institute regular monitoring for pulse, blood pressure, temperature<br> ❑ ECG monitoring<br> ❑ Check glucose level, and correct hypoglycemia if present '''( | {{familytree | | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | |B01='''General measures (Emergency):'''<br><div style="float: left; text-align: left; line-height: 150% "> '''Begin initial care:''' <br>❑ Turn patient to side <br> ❑ Secure airway<br> ❑ Assess respiratory and cardiac functions <br> ❑ Administer high concentration O<sub>2</sub> <br> ❑ Establish IV access<br> ❑ Institute regular monitoring for pulse, blood pressure, temperature<br> ❑ ECG monitoring<br> ❑ Check glucose level, and correct hypoglycemia if present '''(Emergency)''' | ||
---- | ---- | ||
'''Order labs:''' <br> ❑ Full blood count <br> ❑ Plasma electrolytes <br> ❑ Blood gases <br> ❑ Glucose <br> ❑ Renal and liver function<br>❑ Serum calcium and magnesium<br> ❑ Blood clotting <br> ❑ Drug levels (if patient is on AED) <br> ❑ Obtain 5 ml of serum and 50 ml of urine sample for toxicology screen | '''Order labs:''' <br> ❑ Full blood count <br> ❑ Plasma electrolytes <br> ❑ Blood gases <br> ❑ Glucose <br> ❑ Renal and liver function<br>❑ Serum calcium and magnesium<br> ❑ Blood clotting <br> ❑ Drug levels (if patient is on AED) <br> ❑ Obtain 5 ml of serum and 50 ml of urine sample for toxicology screen | ||
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---- | ---- | ||
'''Treat acidosis if severe''' | '''Treat acidosis if severe''' | ||
</div>}} | </div>}} | ||
{{familytree | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | |C01='''Administer AED (Emergency):'''<br> <div style="float: left; text-align: left; line-height: 150% "> | {{familytree | | | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | |C01='''Administer AED (Emergency):'''<br> <div style="float: left; text-align: left; line-height: 150% "> | ||
❑ First line therapy: IV [[lorazepam]] (0.1 mg/kg at 2 mg/min, 4 mg bolus) | ❑ First line therapy: IV [[lorazepam]] (0.1 mg/kg at 2 mg/min, 4 mg bolus) | ||
<br> or <br> | <br> or <br> | ||
❑ 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</div>}} | ❑ 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</div>}} | ||
{{familytree | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | | | | I01 | | | | | | | | | | | | | | | | | | | | | |I01='''Ongoing seizure 60 mins after onset? ( | {{familytree | | | | | | | | | | | | | | | | | E01 | | | | | | | | | | | | | | | | | | | | | |E01= '''Recurrent or ongoing seizure 10 min after onset? (Emergency)''' <br><br><div style="float: left; text-align: left; line-height: 150% "> ❑ Repeat the previous regimen only '''ONCE'''</div>}} | ||
{{familytree | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | | | G01 | | | | | | | | | | | | | | | | | | | | | |G01='''Recurrent or ongoing seizure 30 mins after onset? (Emergency)''' <br><div style="float: left; text-align: left; line-height: 150% "> ❑ IV [[phenytoin]] (15-18 mg/kg at 50 mg/min): Slow IV infusion, IM is not recommended, monitor ECG during the infusion<br> or <br> ❑ IV [[fosphenytoin]] (15-20 mg phenytoin equivalents (PE)/kg at 50-100 mg PE/min): monitor ECG during the infusion<br> or <br> ❑ IV [[phenobarbital]] (10-15 mg/kg at 100 mg/min)</div>}} | |||
{{familytree | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | | | I01 | | | | | | | | | | | | | | | | | | | | | |I01='''Ongoing seizure 60 mins after onset? (Emergency)'''<br><div style="float: left; text-align: left; line-height: 150% "> ❑ Intubate and ensure full intensive care support <br> ❑ Anesthetize with midazolam (0.1-0.2 mg/kg bolus, then 0.05-0.5 mg/kg/hour), OR [[thiopental]] (3-5 mg/kg bolus, then 3-5 mg/kg/hour, OR [[propofol]] (1-2 mg/kg bolus, then 2-10 mg/kg/hour) titrated to effect; reduce the dose after 2-3 days as fat stores are saturated <br> ❑ ICU admission </div>}} | |||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 17:50, 18 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 a 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.
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
- Brain trauma
- Cerebrovascular disorders
- Electrolytes abnormalities
- Hypoglycemia
- Infections
- Low antiepileptic drug levels in patients with epilepsy[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: ❑ Aura: altered vision and/or hearing and/or ❑ Tonic phase with muscle spasms and/or ❑ Rapid jerky movement and/or ❑ Uprolling of eyes and/or ❑ Tounge bite and/or ❑ Incontinence | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
General measures (Emergency): Begin initial care: ❑ Turn patient to side ❑ Secure airway ❑ Assess respiratory and cardiac functions ❑ Administer high concentration O2 ❑ Establish IV access ❑ Institute regular monitoring for pulse, blood pressure, temperature ❑ ECG monitoring ❑ Check glucose level, and correct hypoglycemia if present (Emergency) Order labs: Consider vitamin deficiencies: Consider the possibility of non-epileptic status Treat acidosis if severe | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Administer AED (Emergency): | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Recurrent or ongoing seizure 10 min after onset? (Emergency) ❑ Repeat the previous regimen only ONCE | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Recurrent or ongoing seizure 30 mins after onset? (Emergency) ❑ IV phenytoin (15-18 mg/kg at 50 mg/min): Slow IV infusion, IM is not recommended, monitor ECG during the infusion or ❑ IV fosphenytoin (15-20 mg phenytoin equivalents (PE)/kg at 50-100 mg PE/min): monitor ECG during the infusion or ❑ IV phenobarbital (10-15 mg/kg at 100 mg/min) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ongoing seizure 60 mins after onset? (Emergency) ❑ Intubate and ensure full intensive care support ❑ Anesthetize with midazolam (0.1-0.2 mg/kg bolus, then 0.05-0.5 mg/kg/hour), OR thiopental (3-5 mg/kg bolus, then 3-5 mg/kg/hour, OR propofol (1-2 mg/kg bolus, then 2-10 mg/kg/hour) titrated to effect; reduce the dose after 2-3 days as fat stores are saturated ❑ ICU admission | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Adapted from the 2012 National Institute for Health and Care Excellence (NICE) clinical guidelines.
Do's
Dont's
References
- ↑ 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.