Status epilepticus resident survival guide: Difference between revisions
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{{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]] | {{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> ❑ Tongue 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 '''(Emergency)''' | {{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)''' | ||
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{{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, rate not critical, 4 mg bolus) | ❑ First line therapy: IV [[lorazepam]] (0.1 mg/kg, rate not critical, 4 mg bolus) | ||
<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 | | | | | | | | | | | | | | | | | 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 | | | | | | | | | | | | | | | | | 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 | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{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> | {{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 | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{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% "> | ||
'''Start anesthesia (reduce the doses after 2-3 days):'''<br> | |||
❑ [[Midazolam]] (0.1-0.2 mg/kg bolus, then 0.05-0.5 mg/kg/hour) titrated to effect<br> | |||
OR,<br> | |||
[[Thiopental]] (3-5 mg/kg bolus, then 3-5 mg/kg/hour) titrated to effect<br> | |||
OR,<br> | |||
[[Propofol]] (1-2 mg/kg bolus, then 2-10 mg/kg/hour) titrated to effect<br> | |||
---- | |||
'''Ensure full intensive care support'''<br> | |||
❑ Intubate <br>❑ ICU admission and continuous monitoring</div>}} | |||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 18:08, 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 ❑ Tongue 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 alternative diagnosis: 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) Start anesthesia (reduce the doses after 2-3 days): Ensure full intensive care support ❑ ICU admission and continuous monitoring | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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.