Professional Documents
Culture Documents
Muhammad Akbar
Department of Neurology
Hasanuddin University
General
Drugs
Status Epilepticus-Definition
1. Major motor (convulsive) status
Three(3) seizures uninterrupted by
consciousness or a single prolonged seizure greater
than 1/2 hour.
2. Spike wave stupor (Absence or Petit mal status) and
complex partial (psychomotor) status are prolonged
alterations of consciousness verified by EEG as
epileptic.
Status epilepticus
General
Drugs
Epidemiology - SE
life threatening
USA: -102,000 -152,000 cases / year
- 52,000 deaths / year
of new cases of epilepsy, 12 -30%
present in Status
generalized Status is most common
form - and subject of this review
General
Drugs
Clinical - Generalized SE
at onset - usu obvious tonic / clonic
as continues often subtle - slight twitch of
face / extremities, nystagmoid eye
movements
may be NO observable motor sz ***still
risk for CNS injury - assume still seizing if
SE pt not waking
General
Drugs
Outcome of SE
overall adult mortality 20% (>80 yr : 50%)
>90% mortality is d/t underlying disease
children - better outcomes - mortality 2.5 %
increase risk future SE / chronic sz
worse outcome if prolonged / severe
physiologic disturbance
outcome depends on cause - acute vs chronic
Outcome of SE
continued
Outcome of SE
continued
General
Drugs
Pathophysiology - SE
Pathophysiology - SE contd
Pathophysiology - SE
continued
Pathophysiology - SE
continued
Pathophysiology - SE
continued
Pathophysiology - SE
continued
General
Drugs
OUTLINE - Management of SE
General approach
Anti - Epileptic Drugs:
Benzodiazepines
Phenytoin / Fosphenytoin
Barbiturates
Propofol
others / new possibilities
Management of SE
ABCs (+ monitor / O2 / large IVs)
START PHARMACOTHERAPY ASAP
Metabolic acidosis common - if severe, give
Bicarb
if intubating / ventilating - avoid longacting n-m blockers - masks sz activity
beware hyperthermia 2 sz - in 30-80%
--> passive cooling
Management of SE
continued
Management of SE
continued
tonic-clonic
look for signs of underlying causes - trauma,
infection, etc
Management of SE
continued
consider....
Thiamine
Glucose
Pyridoxine 5 gm IV (70 mg/kg kids)
reverses INH action inhibiting GABA
synthesis
now recommended routinely by NYC Poison
Control in REFRACTORY SE d/t frequency
of INH OD
OUTLINE - Management of SE
General approach
Anti - Epileptic Drugs:
Benzodiazepines
Phenytoin / Fosphenytoin
Barbiturates
Propofol
others / new possibilities
Drug Rx of SE
Drug Rx of SE
easy to administer
prompt onset, long-acting
100% effective vs seizures
no depression of cardio-resp function or mental
status
no other adverse effects
OR
Lorazepam - 4 mg IV push (2mg/min) may
be repeated.
i. Fast acting, medium lasting.
ii. Respiratory depression only in the
extubated patient.
Drug Rx of SE
Drug Rx of SE
1st - Benzodiazepines
* Lorazepam, Diazepam
2nd - Phenytoin, Fosphenytoin
3rd - Phenobarbital
Drug Rx - Refractory SE
Non - IV Rx of SE
Lorazepam
1st agent to use
Dose: Adults 4 -10 mg (.1 mg/kg) IV
Peds .05 - .1 mg/kg (to 4 mg) IV
less lipid soluble than Diazepam --> smaller
volume of distribution / longer T1/2
effects last 12 - 24 hr
S/E: resp depression, hypotension, confusion,
sedation (but less than diazepam)
Diazepam
Dose: Peds .1-1.0 (.2-.5) mg/kg IV
Adults 10 - 20 mg (.2 mg/kg) IV
Duration of action: < 1 hr
Lorazepam
Diazepam
*1224hr
*<1hr
23min
13min
++
Midazolam
Dose: .2 mg/kg IV
5-10 mg IM
0.2 mg/kg Intranasal
Dose for refractory SE - continuous IV
infusion @ .1 - 2.0 mg/kg/hr - titrated
Onset: IV 2 - 3 min / other routes 15 min
Duration: 1 - 4 hr
Phenytoin (Dilantin)
still the standard 2nd IV Rx after Benzo
dose: 18 - 20 mg/kg (better than 1 gram)
IV solution is highly alkaline - dissolved in
propylene glycol, alcohol, and NaOH
- pH is 12
-give in large vein, dilute N/S, flush
rate: 50 mg / min (Peds: 1 mg/kg/min)
onset of action: 10 - 30 min
duration of action: 12 - 24 hr
Phenytoin
continued
Fosphenytoin
a prodrug of Phenytoin
it has no anticonvulsant action itself, but is
rapidly converted to Phenytoin
Dosage: in Phenytoin Equivalents to attempt
to avoid confusion
Molecular wt = 1.5 x Phenytoin ... so
1.5 mg Fosphen --> 1 mg Phenytoin
can safely give at 3x rate of Phenytoin,
resulting in 2x amount of Phenytoin delivered
Fosphenytoin
Fosphenytoin
Negative considerations:
COST Approx 20x that of Phenytoin
CONFUSION of ordering in Phenytoin
equivalents
can give IV at rate of 150 PE/min, which
delivers 100 mg/min of Phenytoin
750 mg Fosphen = 500 mg PE
- One
UK hospital expresses orders in both
units ie 500 mg PE (750 mg Fosphen)
Fosphenytoin
confusion:
case report (Epilepsia 42(2): 288, 2001)
- 25 yo female given infusion of Phenytoin
(mistaken for Fosphenytoin) at 150 mg/min
bradycardia to 34
BP dropped to 45/0
asystole
oops.
resuscitated with CPR ( x 15 min),
intubation, atropine, isoproterenol
Fosphenytoin
NOTES both Fosphen (Cerebyx) and Dilantin are
marketed by Parke-Davis
Fosphen was developed to solve problems
associated with parenteral Phenytoin, and
eventually replace it
P-D have stopped making IV Dilantin - but
generic IV Phenytoin still available
Fosphenytoin
Barbiturates
in use since 1912
general CNS depressant activity
Phenobarbital
Dose: 20 mg/kg IV (range 10-40 mg/kg)
-usu maximum 1 gm
Maximum rate: 100 mg/min
onset of action: 10 - 20 min
duration of action: 1 - 3 days
Phenobarbital
Pentobarbital
Dose: 5 - 12 mg/kg
Rate: 5 - 20 mg/min
Thiopental
Dose: 2-5 mg/kg IV
rapid onset: 30 - 60 sec
short duration: 20 - 30 min
S/E:
Thiopental
Propofol
Dose: 1-2 (3-5) mg/kg
Rate: 5-10 mg/min (1-15 mg/kg/hr)
Onset: 2-4 min
Half-life: 30-60 min
does not accumulate --> rapid recovery
Mechanism:
Propofol
Propofol
Advantages over Barbiturates
less hypotension
more rapid onset of action
rapid elimination
Pro-convulsant effect - is now thought to
be myoclonus, unlikely a significant
problem
Paraldehyde
Ketamine in SE
Ketamine in SE
Consensus Guidelines
Rx of Status Ep. in Children
by the Status Epilepticus Working Party Britain 2000
based on literature search of Ped SE papers
in English ; >1100 found, though only 2
were pediatric RCTs
Consensus Guidelines:
if IV Access
1. Lorazepam 0.1 mg/kg (over 30-60 sec)
2. Lorazepam - repeat
3. Phenytoin 18 mg/kg (over 20 min)
OR Phenobarbital 20 mg/kg (over 10
min) if already on Phenytoin
AND Paraldehyde rectally 0.4 ml/kg in
same volume olive oil
4. RSI - Thiopental induction 4 mg/kg
Consensus Guidelines:
if NO IV Access
1. Diazepam 0.5 mg/kg rectally
2. Paraldehyde 0.4 ml/kg rectally
start intraosseous if still no IV
then follow IV algorithm
4. RSI using Thiopental
3. Phenytoin / Phenobarb; plus Paraldehyde
rectally
Consensus Guidelines
Thank You
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TERIMA KASIH