Status%20Epilepticus

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Status Epilepticus
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Status Epilepticus

• S?ßa?? epe????sa ?at???? ?at?stas? p?? ????e?
  ?µes?? pa??µßas??

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Status Epilepticus

• ?p?p?????
• ?????µ?e?
• ??ata?a??? ??S
• ?e????e??? p?e?µ????? ??d?µa
• ?pe??e?µ?a
• ?aßd?µ????s?
• ??s??f?s?
• ????µ? ?e????????? ß??ß?

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???sµ??

• S??e??? ep???pt??? d?ast????t?ta gt 30 ?ept?? ?
• ?? µeta?? 2 ???se?? de? ?p???e? p????? a??????
  t?? ep?p?d?? s??e?d?s??
• ???? ???sµ?? ep???pt??? ???s? gt 5 ?ept?? ? e
  ep???pt???? ???se?? ????? ?a epa????e? e?d??µesa
  t? ep?ped? s??e?d?s??

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?p?t??p?????sa ep???pt??? ???s?

• ?????e?a p??? ap? 2 ??e?
• 2 ? pe??ss?te?a epe?s?d?a µ?sa se 1 ??a pa?? t??
  ?e?ape?a ?
• µ? a?tap??????µe?? st?? a???? ep???pt??? ???s?

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?a????µ?s?

• Electroclinical features,
• (convulsive status epilepticus)
• (nonconvulsive status epilepticus)
• ?p??e?????
• whole brain (generalized status epilepticus) ?
• part of the brain (partial status epilepticus).

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?p?d?µ??????a

• 150,000 cases of status epilepticus and
• 55,000 deaths from it occur annually in the
  United States.
• An incidence of between 6.2 and 18.3 per 100,000
  population has been reported in the United States

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??t??????a
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St?d?a

• The first stage generalized convulsive
  tonic-clonic seizures that are associated with an
  increase in autonomic activity that results in
• hypertension,
• hyperglycemia,
• sweating,
• salivation, and
• hyperpyrexia
• Second phase 30 min of seizure activity,
  characterized by
• failure of cerebral autoregulation,
• decreased cerebral blood flow, an
• increase in intracranial pressure, and
• systemic hypotension.
• Electromechanical dissociation may occur

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??????s?

• ??????? e????a
• ??G apa?a?t?ta

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Te?ape?a

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• ??????? ?e?????????? ß?aß?? ?a? s?st?µat????
  ep?p?????
• ??a??p? spasµ??
• ???stas?a ae?a?????
• ??????? e?s??f?s??
• Te?ape?a ?p??e?µe??? p???s??

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Ge???? µ?t?a

• ?pa???? ae??sµ?? ???????s?
• S?st? ??s? as?e????
• 2 f?eß???? ??aµµ?? ???? f??µa?a
• ??as?????s? t?a?e?a?

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• Lorazepam
• Propofol,
• Midazolam, or
• Etomidate
• Rocuronium (1 mg/kg)
• Succinylcholine

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???a µ?t?a

• Hypoglycemia
• 100 mg IV thiamine
• 50 dextrose
• BP, ECG, and temperature
• Hyperthermia (ie, temperature 40C), then passive
  cooling
• Serum chemistry levels
• Myoglobin
• Hydration is necessary to prevent
  myoglobin-induced renal failure. urinary
  alkalinization
• Brain imaging with a CT scan and/or MRI
• Lumbar puncture
• Endotracheal intubation and
• Neuromuscular

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F??µa?a

• Diazepam,
• Lorazepam,
• Midazolam,
• Phenytoin,
• Fosphenytoin, and
• Phenobarbital
• have all been used as first-line therapy for the
  termination of status epilepticus.

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F??µa?a

• lorazepam, 0.1 mg/kg
• diazepam, 0.15 mg/kg, followed by 18 mg/kg
  phenytoin
• phenytoin, 18 mg/kg and
• phenobarbital, 15 mg/kg
• Status epilepticus was terminated in 64.9 of
  patients randomized to lorazepam, 58.2 of those
  randomized to phenobarbital, 55.8 of those
  randomized to diazepam and phenytoin, and 43.6
  of those randomized to phenytoin (p 0.002 for
  lorazepam vs phenytoin)

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Pathophysiology of CNS Emergencies

• Structural Changes
• Often due to Trauma but not always
• Circulatory Changes
• Inadequate Perfusion
• Alterations of ICP
• Response to insult
• Toxic Metabolic states
• Alteration to blood chemistry or introduction of
  toxins
• Psychiatric mimicking

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Altered Mental Status
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Coma

• A decreased state of consciousness from which a
  patient cannot be aroused
• Mechanisms
• Structural lesions
• Toxic Metabolic states
• Psychiatric mimicking

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Brain injury

• Recall that Brain injury is often shown by
• Altered Mental Status
• Seizures
• Localizing signs

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Is unconsciousness itself an immediate life
threat?
YES, IT IS!

• Loss of airway
• Vomiting, aspiration

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Altered Mental State
Manage ABCs Before Investigating Cause!
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Initial Assessment/Management

• Airway
• Open, clear, maintain
• If trauma or history, control C-spine
• Breathing
• Presence? Adequacy (rate, tidal volume)?
• High concentration O2 on ALL patients with
  altered mental status
• Assist ventilations prn
• Circulation
• Pulses? Adequate Perfusion?

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Investigate Cause

• DERM
• D Depth of Coma
• E Eyes
• R Respiratory Pattern
• M Motor Function

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D Depth of Coma

• What does patient respond to?
• How does he respond?

Avoid use of non-specific terms like stuporous,
semi-conscious, lethargic, obtunded
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D Depth of Coma

• AVPU
• Glasgow Scale (later)

Describe level of consciousness in terms of
reproducible findings
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E Eyes

• Pupils
• Size - mid, dilated or constricted
• measurement - e.g. 4 mm
• Shape - round, oval, pontine
• Equality - equal in size
• Symmetry - equal in reaction/response
• Response to light
• Yes or No
• How?

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R Respiratory Pattern

• Depth
• Unusually deep or shallow?
• Pattern
• Regular or Unusual pattern
• Can you identify the pattern?

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M Motor Function

• Paralysis?
• Where?
• Muscle tone?
• Rigid or Flaccid
• Movement?
• Where? What is it like?
• Posturing?
• How?
• Symmetrical Motor Function?

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Physical Exam

• Vital Signs
• Shock?
• Increased ICP?
• Hypoxia/Hypercarbia
• Diagnostics
• Dysrhythmias?
• Blood glucose
• Oxygen saturation

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Physical Exam

• Detailed (Head-to-Toe) Exam
• Injuries causing coma?
• Injuries caused by coma?
• Clues to the cause

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Probable Causes of AMS

• Not enough Oxygen
• Not enough Sugar
• Not enough blood flow to deliver oxygen, sugar
• Direct brain injury
• Structural
• Metabolic

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Differentiating AMS Causes

• Structural
• Asymmetrical deficits
• Unequal pupils
• Afebrile
• History of trauma, structural abnormality
• Often a rapid onset

• Metabolic
• Symmetrical deficits
• Equal pupils (? altered function)
• ? Fever
• History of metabolic disorder or illness
• Rapid onset less likely

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Management

• Maintain ABCs
• Attempt to identify cause
• Mainstays of therapy
• Oxygenation/Ventilation
• IV fluids appropriate for the patient
• D50 (if hypoglycemic)
• Narcan if possibility of opiate OD
• Flumazenil in known benzo only OD

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AEIOU TIPS

• Alcohol
• Epilepsy
• Insulin
• Overdose
• Uremia (Metabolic causes)

• Trauma
• Infection
• Psychogenic
• Stroke/Syncope

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SeizuresAEIOU TIPS
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Seizures

• Alteration in behavior/consciousness 2 unstable,
  uncoordinated electrical activity in the brain
• Often a result of altered membrane permeability
• Manifested by sudden, brief episodes of
• altered consciousness
• altered motor activity
• altered sensory phenomena
• unusual behavior

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Seizure Categories

• Generalized
• Tonic-Clonic (grand mal)
• AKA Convulsions
• Absence (petit mal)
• Partial
• Simple partial
• Complex partial
• Hysterical

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Seizure Etiology

• Head trauma
• Hypoglycemia
• Brain neoplasms
• Psychiatric disorders
• Eclampsia
• Hypocalcemia

• CVA
• Hypoxia
• Infection/Fever
• Drug/alcohol withdrawal
• Poisoning/OD
• Thyrotoxicosis

Anything that injures brain can cause seizures
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Seizures Etiology
Most epileptic seizures are idiopathic in origin
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Generalized Seizures

• Grand mal
• aka Convulsions
• Common
• Often w/Aura
• Sudden LOC
• Tonic / Clonic
• Postictal phase
• Status epilepticus

• Petit Mal
• Absence Sz
• Children
• No LOC

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Generalized Seizures

• Symmetrical
• No local onset
• Irritable focus difficult to identify
• Near simultaneous activation of entire cortex
• Focus may begin deep in brain and spread outward

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Generalized Seizures

• Tonic-Clonic Seizures (Grand Mal)
• Aura (preictal phase)
• Loss of consciousness/postural tone
• Tonic phase
• Hypertonic (tetanic) phase
• Clonic phase
• Post-ictal phase
• May experience transient neurologic deficits
  (Todds paralysis)

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Generalized Seizures

• Absence Seizure (Petit Mal)
• Brief loss of awareness (10 - 30 seconds)
• Usually no loss of postural tone
• May occur 100 times a day
• Primarily pediatric problem
• Often described as daydreaming, not paying
  attention
• Usually disappear as child matures

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Partial Seizures

• Seizure begins locally
• May remain localized or spread to entire cortex
• Result from focal structural lesion in brain

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Partial Seizures

• Simple
• Localized clonic activity
• Abnormal sensory symptoms
• Usually no LOC
• May progress
• Jacksonian March (Seizure)

• Complex
• Change in behavior
• Preceded by aura
• Repetitive motor behavior
• No recall
• May progress

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Partial Seizures

• Simple partial seizures (No
  loss of consciousness)
• Focal motor seizures
• Local clonic activity
• May display Jacksonian march
• Sensory seizures
• Autonomic seizures

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Partial Seizures

• Complex partial seizure (psychomotor or temporal
  lobe seizures)
• Distinctive aura
• Loss of consciousness
• Automatisms
• May be mistaken for drunks or psychotics
• May experience episodes of rage

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Hysterical Seizures

• Usually in front of audience
• Usually follow interpersonal stress
• Movements asymmetrical or purposeful
• Does not fall, hit head, bite tongue
• Incontinence rare
• Recalls things said, done during seizure

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Assessment

• Seizure Assessment
• Duration
• Seizure
• Postictal phase
• Typical for the patient?
• Onset
• Events before
• HA
• Aura
• Trauma
• Vision Disturbances

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Assessment

• Recent History
• Trauma to the head/brain
• HA / Neck Pain
• Pregnancy
• Brain tumor
• Recent Infection/Illness
• CVA Symptoms
• Introduction of Poisons into body

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Assessment

• Past History
• Diabetes Mellitus
• Seizure Disorder
• Tumor
• CVA
• Medications
• Recreational Drug Use
• Alcohol abuse

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Assessment

• Physical Exam
• Evidence of trauma
• Evidence of alcohol, drug abuse
• Rash, stiff neck
• Pregnant
• CVA Signs
• Incontinence

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Status Epilepticus

• Two or more seizures without intervening
  conscious period
• Usually due to medication non-compliance
• Management same as for other Seizures just more
  aggressive

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Seizure Management

• Patient actively seizing
• Do NOT restrain
• Do NOT put anything in mouth
• Oxygen NRB if possible
• ECG Monitor when possible
• IV Access
• Lg Bore, NS
• Assess blood glucose

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Seizure Management

• Patient actively seizing
• If hypoglycemic Assess IV patency FIRST!!
• Dextrose 50 12.5 - 25 grams IV push
• Consider Thiamine 100 mg slow IV push
• Diazepam, slow IV administration until seizure
  stops or until 10 mg
• Usually aimed at 2.5 mg doses, one after another
• Phenobarbital, 100 mg/min IV push to a total 390
  mg or seizure stops
• Barbiturate coma
• NMB Intubation

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Seizure Management

• Current Mainstays of Therapy for Actively Seizing
  Patient
• Diazepam
• Lorazepam
• Phenobarbital
• New Therapy
• Phosphenytoin
• Other Considerations
• Glucose
• MgSO4
• Paraldehyde
• Dilantin (phenytoin) 18mg/kg at 25 mg/min

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Seizure Management

• After seizure stops
• Open -Clear- Maintain airway
• O2 via NRB
• Assist ventilations if needed
• Roll patient onto side protecting head
• Reassess ABCDs
• Assess blood glucose
• Physical Exam and History
• Most seizure deaths are due to anoxia

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Seizure Management
If the patient is epileptic, do these seizures
match what is normal for him?
Just because the patient is epileptic, he does
NOT have to be having an epileptic seizure!
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Mandatory Transports

• First time seizures
• Seizure patient off medications
• Change in seizure pattern
• Associated with trauma
• Pregnant patient
• Status epilepticus
• Associated with increased body temperature
• Not always Seldom in young children
• Has infection been diagnosed and treatment
  initiated?

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Anti-seizure Medications

• Seizures caused by hyperactive brain areas
• Multiple chemical classes of drugs
• All have same approach
• Decrease propagation of action potentials
• ? Na, Ca influx (delay depolarization/prolong
  repolarization)
• ? Cl- influx (hyperpolarize membrane)

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Anti-Seizure Medications

• Benzodiazepines
• diazepam (Valium)
• lorazepam (Ativan)
• Barbiturates
• phenobarbital (Luminal)

• Ion Channel Inhibitors
• carbamazepine (Tegretol)
• phenytoin (Dilantin)
• Misc. Agents
• valproic acid (Depakote)

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Outline of Clinical Problems

• Altered mental status---most common consult
• Seizures
• Stroke
• Delirium/dementia
• Infections
• Focal weakness
• Diffuse weakness
• Trouble breathing
• Trouble swallowing

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Seizures

• Gen tonic/clonic complex partial absence
  myoclonic
• Causes usually metabolic
• Hypoxia, drugs, d/c AEDs
• Can be seen with strokes, infections (meningitis,
  encephalitis, abscess)
• Prolonged post-ictal phase
• Sub-clinical seizures--must use an EEG
• Cause of AMS

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