Transcript taking load cardio respiratory stop

Mozhdehi panah.MD
Neurologist
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Definition
Etiology
Treatment
Complication
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ILAE define 20 years ago as a single seizure
of >30 minute duration or a series of
epileptic seizures during which function is
not regained between ictal event in a 30
minute period.
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Status should be interrupted urgently due to
decrease mortality ,cardiorespiratory
morbidity or refractory status.
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>5 minutes of continious seizures or
2 or more seizures between which there is
incomplete recovery of consciousness
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Ongoing convulsive or nonconvulsive
seizures following administration of an initial
benzodiazepine and a nonbenzodiazepine
AED , given in appropriate dose.
Incidence : 30%
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Generalized Convulsive Status Epilepticus
(GCSE)
Focal motor status epilepticus
Myoclonic status epilepticus
Tonic status epilepticus
Non Convulsive Status Epilepticus (NCSE)
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Incidence : 7-41 per 100,000
Bimodal age distribution : peak incidence rate
in <1 and above 60 years .
Acute symptomtic
Remote symptomatic
AED nonadherence
Withdrawal syndrome
Metabolic abnormality or sepsis
Use of drugs that lower seizure treshold
Autoimmune or paraneoplastic encephalitis
New onset refractory status
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Stroke,head traume, SAH, cerebral hypoxia
Infection (encephalitis ,meningitis, abscess)
Brain tumor
Acute symptomtic
 Remote symptomatic
AED nonadherence
Withdrawal syndrome
Metabolic abnormality or sepsis
Use of drugs that lower seizure treshold
Autoimmune or paraneoplastic encephalitis
New onset refractory status
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Prior head injury or neurosurgery, perinatal
cerebral ischemia, AVM,benign brain tumor
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Acute symptomtic
Remote symptomatic
AED nonadherence
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Acute symptomtic
Remote symptomatic
AED nonadherence
Withdrawal syndrome
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Alcohol
Barbiturate
Benzodiazepines
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Acute symptomtic
Remote symptomatic
AED nonadherence
Withdrawal syndrome
Metabolic abnormality or sepsis
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Hypoglycemia
Hepatic encephalopathy
Uremia
Hyponatremia
Hyperglycemia
Hypocalcemia
hypomagnesemia
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Acute symptomtic
Remote symptomatic
AED nonadherence
Withdrawal syndrome
Metabolic abnormality or sepsis
Use of drugs that lower seizure treshold
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Theophylline
Imipenem
High dose of penicillin G
Quinolone
Metronidazole
INH
Tricyclic antidepressant
Bupropion
Lithium
Clozapine
Flumazenil
Cyclosporine
Lidocaine
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Acute symptomtic
Remote symptomatic
AED nonadherence
Withdrawal syndrome
Metabolic abnormality or sepsis
Use of drugs that lower seizure treshold
Autoimmune or paraneoplastic encephalitis
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Acute symptomtic
Remote symptomatic
AED nonadherence
Withdrawal syndrome
Metabolic abnormality or sepsis
Use of drugs that lower seizure treshold
Autoimmune or paraneoplastic encephalitis
New onset refractory status
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Initial assessment and suport
Initial pharmacologic therapy
Alternative second line therapies
Out of hospital/prehospital treatment
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Assessment of cardiorespiratory function
Oral airway
Intravenous line
Blood is drawn for glucose, BUN, electrolytes,
and a metabolic and drug screen.
Normal saline infusion
Glucose (with thiamine if malnutrition and
alcoholism are potential factors).
1-Benzodiazepines
2-Non-Benzodiazepine AED
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Lorazepam 0.1 mg/kg , upto 4mg per dose
Diazepam 0.15 mg/kg ,up to 10 mg per dose
Midazolam 5-10 mg IM
Clobazam
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First-line (Grade 1A)
Time of from its injection to its maximum
effect : 2 min
Effective duration of action against seizure :
4-6 hours
Rate of injection : 2 mg/min
This should be repeated after 1 min if seizure
continue.
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High lipid solubility
Rapidly cross BBB
Rapid onset of its effect : 10-20 seconds
Initial termination of seizure : 50-80 %
Durartion of anticonvulsants effect : <20 min
Recurence of seizure : 50% in 2 hr
Rate of injection : 5 mg/min
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Rectal gel of diazepam is also available
Provide rapidly delivery , when IV access is
dificult , or for at home use for patients who
have frequent repetitive or prolonged
seizures
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Rapid onset in termination of seizure activity :
less than 1 minute
Short half life in CNS
Administration route: IM , buccal , intranasal
Very effective when IV access is not available :
pre-hospital treatment
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Onset of effect between diazepam and
lorazepam
Duration of effect is more prolonged than
diazepam
IV injection
Can be used in refractory status as adjuant
therapy when given entrally by NG tube.
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Lorazepam IV : 4mg
Midazolam IM : 5-10 mg
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Fosphenytoin or phenytoin
Valproate
Phenobarbital
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First line (Grade 2C)
Preferred formulation of phenytoin
Water-soluble
Loading dose: 20-30 mg/kg
Lower risk of irritation at injection site
Rate of infusion :100-150 mg/min
However, the delay in hepatic conversion of
fosphenytoin to active phenytoin makes the
latency of clinical effect approximately the
same as phenytoin
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Can be given intramuscularly in cases where
venous access is difficult ,however less
predictable effect and longer time to onset of
seizure activity
Less cardiovascular effect compare to
phenytoin
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loading dose : 20 mg/kg
Intravenous
Rate of injection: less than 50 mg/min
If seizures continue, an additional 5 mg/kg is
indicated
More rapid administration risks hypotension
and heart block
Must be given through a freely running line
with normal saline (it precipitates in other
fluids)
Should not be injected intramuscularly.
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Phenytoin (but not phosphenytoin) and any of
the benzodiazepines are incompatible and
will precipitate if infused through the same
intravenous line
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In an epileptic patient known to be taking
anticonvulsants chronically but in whom the
serum level of drug is unknown, it is probably
best to administer the
full-recommended dose of phenytoin
Preferred to phenytoin in primary CGSE
Loading dose: 20mg/kg
FDA approved only for slow infusion rate
:20mg/ min
Rate of seizure control ; 50-90%
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Loading dose:20mg/kg
Infusion rate: 30-50mg/min
Intuabation is often required to provide
secure airway
Side efects :sedation , respiration arrest
Half life : 87-100 hr
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Loading dose : 2000-4000 mg
Seizure control rate : 68%
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Loading dose : 200-400 mg , IV
Side effect: third degree AV block, angioedema
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Ongoing convulsive or nonconvulsive
seizures following administration of an initial
benzodiazepine and a nonbenzodiazepine
AED , given in appropriate dose
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The optimal treatment of RSE is more
contoversial.
It is critical to provide adequate ventilatory
and hemodynamic support
Patients should be intubated and monitored
by continious electroencephalogram.
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Primary drugs used for RSE:
-Midazolam
-Propofol
-Pentobarbital
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Main points in selection of drugs:
-Urgency of seizure control
-Pharmakokinetic of various drugs
-Drugs already used and failed
-Potential complication of treatment
(hypotension & risk of prolonged MV)
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Pentobarbital is more popular ,because more
seizure control rate , but has more sedation
and more ventilatory need
Pentobarbital and propofol have greater risk
of hemodynamic instability.
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Midazolam & propofol have advantages for
patients at risk for ventilatory dependence
with prolonged therapy(severe pulmonary
disease ,severe debilitation, or malignancy)
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Water soluble, rapidly acting banzodiazepine
loading dose : 0.2 mg/kg
Infusion rate : 2mg/min
Additional dose should be given every 5
min,until seizure stop (max dose : 2 mg/kg)
Followed by an continious infusion of 0.1 to
0.4 mg/kg/h(can be titrated upwardly upto
5mg/kg/hour) with control of blood pressure
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If seizure continue within 45-60 minute,
propofol or pentobarbital should be started
Side effects: hypotension(less common than
pentobarbital) ,tachyphylaxis ,withdrawal
seizure ,
Relapse of seizure is more common when
higher doses is used.
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Highly lipophilic phenol , GABA-A agonist
loading dose : 1-2 mg/kg( in 5 min) and
then repeated until seizure stop
Continious infusion as an intravenous drip of
2 to 8 mg/kg/h may be required but should
not be maintained more than 48 hr.
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Side effects: hypotension, respirstory
depression , propofol infusion syndrome
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Propofol infusion syndrome :
rhabdomyolysis, severe matabolic acidosis
,and cardiac and renal failure
More common in prolonged use (48 hr) and
in infusion rates of greater than 5mg/kg/hr.
ABG, CPK, lactic acid, TG, amylase should be
checked.
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If seizure controlled with propofol , the
effective infusion rate should be maintained
for 24 hr , and then tapered 5% per hr.
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Loading dose:5mg/kg over 10 min.
Max infusion rate :50mg/min
If seizure persist: additional 5mg/ kg dose
Continious infusion rate: 1 mg/ kg/hr
Side effects: hypotension, prolonged sedation
If seizure controlled , infusion must be
continued for 24 hr before discontinuation of
drug.
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Petit mal status should be managed by
intravenous lorazepam, valproic acid, or both,
followed by ethosuximide.
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Nonconvulsive status is treated along the
lines of grand mal status, usually stopping
short of using anesthetic agents.
Myoclonic status is treated with
benzodiazepines and valproate .
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Physical examination
Imaging
LP
EEG
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Rising temperature
Acidosis
Hypotension
Renal failure from myoglobinuria
Epileptic encephalopathy
Aspiration pneumonia
Neurogenic pulmonary edema
Respiratory failure