Diferencia entre revisiones de «Status epilepticus»
(Text replacement - "Category:Neuro" to "Category:Neurology") |
Sin resumen de edición |
||
| Línea 1: | Línea 1: | ||
==Background== | ==Background== | ||
Definitions have | *Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments.<ref>Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9</ref><ref>Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8</ref> Previous definitions used a 30-minute time limit.<ref>Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.</ref> | ||
==Clinical Features== | ==Clinical Features== | ||
*Seizure > 20 minutes. <ref>Brodie MJ Status epilepticus in adults. Lancet. 1990 Sep 1; 336(8714):551-2.</ref> | *Seizure > 20 minutes. <ref>Brodie MJ. Status epilepticus in adults. Lancet. 1990 Sep 1; 336(8714):551-2.</ref> | ||
*Presume status in current seizure > 5 minutes<ref>Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med. 1998; 338:970-976</ref> | *Presume status in current seizure > 5 minutes<ref>Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med. 1998; 338:970-976</ref> | ||
| Línea 11: | Línea 12: | ||
*Clinical diagnosis | *Clinical diagnosis | ||
== | ==Managment== | ||
{{Seizure actively seizing management}} | {{Seizure actively seizing management}} | ||
| Línea 18: | Línea 19: | ||
==External Links== | ==External Links== | ||
EM Nerd [http://emnerd.com/adventure-dancing-men/ Adventure of dancing men] | *EM Nerd [http://emnerd.com/adventure-dancing-men/ Adventure of dancing men] | ||
==See Also== | ==See Also== | ||
Revisión del 08:50 3 abr 2016
Background
- Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments.[1][2] Previous definitions used a 30-minute time limit.[3]
Clinical Features
Differential Diagnosis
Seizure
- Epileptic seizure
- First-time seizure
- Seizure with known seizure disorder
- Status epilepticus
- Temporal lobe epilepsy
- Non-compliance with anti-epileptic medications
- Hyponatremia
- INH toxicity
- Non-epileptic seizure
- Meningitis
- Encephalitis
- Brain abscess
- Intracranial hemorrhage
- Alcohol withdrawal
- Benzodiazepine withdrawal
- Barbiturate withdrawal
- Baclofen withdrawal
- Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia, hepatic failure, uremia
- Eclampsia
- Neurocysticercosis
- Posterior reversible encephalopathy syndrome
- Impact seizure (head trauma)
- Acute hydrocephalus
- Arteriovenous malformation
- Seizure with VP shunt
- Toxic ingestion (amphetamines, anticholinergics, cocaine, INH, organophosphates, TCA, salicylates, lithium, phenothiazines, bupropion, camphor, clozapine, cyclosporine, fluoroquinolones, imipenem, lead, lidocaine, metronidazole, synthetic cannabinoids, theophylline, Starfruit)
- Psychogenic nonepileptic seizure (pseudoseizure)
- Intracranial mass
- Syncope
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
- Post-hypoxic myoclonus (Status myoclonicus)
Diagnosis
- Clinical diagnosis
Managment
Seizure Precautions
- Protect patient from injury
- If possible, place patient in left lateral position to reduce risk of aspiration
- Do not place bite block!
- Jaw thrust, a NPA and oxygen may be required
- An IV line should be placed
Medications
- Benzodiazepine (Initial treatment of choice)[6]
- Midazolam 10 mg (>40 kg), 5 mg (13-40 kg), or 0.2 mg/kg IM[7]
- May also be given IN at 0.2 mg/kg, max 10 mg
- OR buccal at 0.3 mg/kg, max 10 mg
- Lorazepam 0.1 mg/kg IV (max 4 mg) — May repeat one dose[8]
- Diazepam 0.15-0.2 mg/kg IV (max 10 mg) — May repeat one dose; or PR 0.2-0.5 mg/kg (max 20 mg) once[9]
- Midazolam 10 mg (>40 kg), 5 mg (13-40 kg), or 0.2 mg/kg IM[7]
- Secondary medications
- ESETT trial[10] compared second line antiseizure medications and they all are equally efficacious. Therefore may be best to use the one with least side effects [11] which is Levetiracetam
- Levetiracetam 60 mg/kg IV (max 4500 mg) — Preferred in pregnancy; or 1500 mg oral load (preferred in pregnancy)[12]
- Phenytoin 18 mg/kg at ≤50 mg/min IV (avoid in pregnancy)[13]
- Fosphenytoin 20-30 mg PE/kg at 150 mg/min IV — May also be given IM; avoid in suspected toxicology case
- Contraindicated in pts w/ 2nd or 3rd degree AV block
- Valproic acid 20-40 mg/kg at 5 mg/kg/min IV (max 3000 mg) (avoid in pregnancy)[14]
- Refractory medications
- Propofol 2-5 mg/kg load, then 30-200 mcg/kg/min IV
- Midazolam 0.2 mg/kg load, then 0.05-2 mg/kg/hr IV drip
- Ketamine 0.5-3 mg/kg load, then 0.3-4 mg/kg/hr IV[15]
- Lacosamide 400 mg load over 15 min, then 200 mg q12hr IV[16]
- Phenobarbital 15-20 mg/kg at 50-75 mg/min IV — Then 0.5-4 mg/kg/hr drip; titrate to suppression-burst on EEG[17]
- Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)[18]
- Others
- Carbamazepine 8 mg/kg single oral load PO
- Gabapentin 900 mg/day (300 mg TID for 3 days) PO
- Lamotrigine 6.5 mg/kg single oral load PO
Other Considerations
- Secondary causes of seizure (e.g. hyponatremia, hypoglycemia, INH toxicity, ecclampsia)
- Nonconvulsive seizures or status epilepticus - get EEG
Disposition
- Admit to ICU or intermediate level of monitored care depending on etiology, treatments and respiratory status
External Links
- EM Nerd Adventure of dancing men
See Also
References
- ↑ Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9
- ↑ Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8
- ↑ Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.
- ↑ Brodie MJ. Status epilepticus in adults. Lancet. 1990 Sep 1; 336(8714):551-2.
- ↑ Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med. 1998; 338:970-976
- ↑ Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016; 16(1):48-61.
- ↑ McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582
- ↑ Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48
- ↑ Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48
- ↑ Kapur J, Elm J, Chamberlain J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103-2113. doi:10.1056/NEJMoa1905795
- ↑ PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
- ↑ Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
- ↑ Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
- ↑ Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
- ↑ Legriel S, Oddo M, and Brophy GM. What's new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
- ↑ Legros B et al. Intravenous lacosamide in refractory seizure clusters and status epilepticus: comparison of 200 and 400 mg loading doses. Neurocrit Care. 2014 Jun;20(3):484-8.
- ↑ Pugin D et al. Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study. Critical Care 2014. DOI: 10.1186/cc13883.
- ↑ Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.