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STATUS EPILEPTICUS

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STATUS EPILEPTICUS Richard L. Friederich, MD Pediatric Neurology Roseville Kaiser Permanente STATUS EPILEPTICUS -- MORBIDITY & MORTALITY 3-15% mortality 5-40% ... – PowerPoint PPT presentation

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Title: STATUS EPILEPTICUS


1
STATUS EPILEPTICUS
Richard L. Friederich, MD Pediatric
Neurology Roseville Kaiser Permanente
2
Disclosure
  • Under the IMQ/CMA Standards for Commercial
    Support, everyone who is in a position to control
    the content of an education activity must
    disclose all relevant financial relationships
    with any commercial interest. A commercial
    interest includes any proprietary entity
    producing health care goods or services, with the
    exemption of non-profit or government
    organizations and non-health care related
    companies. A financial relationship is relevant
    if it pertains to the activitys content matter
    including any related health care products or
    services to be discussed or presented.
  • Dr Rich Friederich, has disclosed that he has no
    relevant relationships with commercial or
    industry organizations. The CME Department has
    reviewed the disclosure information for the
    planners for this program and they do not have
    relationships that present a relevant conflict of
    interest.

3
Goals
  • To better understand what status epilepticus is
  • To better appreciate importance of early
    intervention in SE
  • To better appreciate importance of a protocol for
    treating SE

4
  • ED call
  • 4 y/o
  • brought in after a 4 minute GTC sz at home
  • 1st seizure ever
  • still post-ictal
  • ED doc asks for the loading dose of Dilantin
  • What do you tell them?

5
STATUS EPILEPTICUS -- DEFINITION
  • Formal seizure or series of seizures producing a
    lasting epileptic condition
  • Informal seizure activity lasting 30 minutes
  • nearly all self-limiting seizures cease w/in 5
    minutes
  • Impending status epilepticus sz gt 5 minutes
  • application any ongoing seizure activity gt5
    minutes

6
STATUS EPILEPTICUS -- EPIDEMIOLOGY
  • 100,000 per year in USA
  • 16 of patients with epilepsy
  • 1/4 occur in pts lt 1 y/o
  • if sz onset lt1 y/o, 70 will have SE
  • 135-156 per 100,000 per year in lt1 y/o

7
Applications
  • No absolute need to bolus a seizure which has
    already ceased
  • No long term prophylaxis for most 1st time
    seizures
  • Exceptions Initial presentation status
    epilepticus
  • focal seizure
  • strong () FHx

8
  • ED call
  • 21 month old
  • presents with a temperature of 104
  • seizure which lasts 40 minutes
  • stops with a single dose of Ativan
  • because the seizure is prolonged, the ED
    physician wants to do a CT. After all, status
    is unusual with febrile seizures (?)
  • What are the most common causes of S.E. in
    children?

9
STATUS EPILEPTICUS MOST COMMON CAUSES
  • Children
  • fever 36
  • med change 20
  • idiopathic 9
  • metabolic 8
  • CNS infection 5
  • HIE 5
  • trauma 3
  • CVA 3
  • EtOH/drug 2
  • tumor 1
  • Adults
  • CVA 25
  • med change 19
  • EtOH/drug 12
  • Anoxia 11
  • Metabolic 9
  • Idiopathic 8
  • Fever 5
  • Trauma 5
  • Tumor 4
  • CNS infection 2
  • DeLorenzo 1992

10
1st sz - neuroimaging
  • Neuroimaging suggested for first time seizure
  • Recommended if SE, focal, or abnl neuro exam
  • MRI better than CT

11
  • You are called to the ED, to await an ambulance
    responding to a call with a 6 y/o boy with
    spastic quad CP and his first-ever seizure, which
    started 25 minutes ago.
  • What is the best treatment to stop the seizures?

12
In-home treatment
  • Diazepam given in the home
  • PR gel form (Diastat)
  • IV valium given PR or IV
  • no difference between PR or IV valium
  • Fosphenytoin given in the home
  • By extrapolation, other PR meds may be as well
  • ? duration SE, ? duration hosp, ? incidence of
    intubation, ? incidence of sz recurrence in ED
  • Alldredge, Ped Neuro 95

Responsiveness to AED
Lowenstein, 1993
13
  • 6 y/o boy with spastic quad CP and his first-ever
    seizure
  • started 25 minutes ago
  • No meds are given at home
  • You run over your mental check list of the order
    in which you will approach things. What are the
    first three things?

14
  • A Airway
  • B Breathing
  • C Circulation

15
  • The patient arrives, still seizing
  • ABCs are OK
  • Realizing that in a real scenario you will
    simultaneously approach both the diagnostic and
    therapeutic aspects
  • What are the drugs you will try?
  • What are their doses?
  • What is the sequence?

16
STATUS EPILEPTICUS -- TREATMENT
  • ABCs
  • Quick evaluation
  • Confirm diagnosis
  • O2, glucose (/- 100mg thiamine), vitamin B6
  • treat underlying etiology
  • Labs levels, Na, glucose, Ca
  • Anticonvulsants
  • Benzodiazepines
  • Diazepam 0.3 mg/kg (max 10mg)
  • Lorazepam 0.1 mg/kg (max 4mg)
  • 20 mg/kg rule
  • phenobarb
  • fosphenytoin
  • valproate
  • levetiracetam

17
STATUS EPILEPTICUS -- ANTICONVULSANTS

Administer over Peak Half-life
Lorazepam 1-2 min 2-5 min 6-16h
Diazepam 1-2 min 2-5 min 30 min
Phenobarb 5-10 min 5-30 min 72 hour
Fosphenytoin 10 min 5-30 min 20 hour
Levetiracetam 15-30 min 30-60 min 20 hour
Valproate 5-10 min 20 min 8 hour
18
STATUS EPILEPTICUS ANTICONVULSANT PROS/CONS
  • Diazepam
  • Rapid efficacy
  • Short effective half life (high fat solubility)
  • Always requires 2nd drug
  • Lorazepam
  • Rapid efficacy
  • Longer half life efficacy
  • Benzodiazepines lose efficacy as SE progresses
  • Phenytoin adverse effects
  • Arrhythmias, hypotension
  • Ppt out in glucose soln
  • Local phlebitis
  • Cannot give IM
  • phenytoin may worsen myoclonic szs
  • Fosphenytoin very expensive
  • levetiracetam may have neuroprotective effect

19
STATUS EPILEPTICUS NEUROPHYSIOLOGY
  • failure of cellular mechanisms to prevent
    sustained seizure activity
  • persistent excitation of NMDA receptors
  • ineffective inhibition at GABA receptors
  • 2 phases
  • Activation
  • Maintenance
  • Becomes self-sustaining after 15-30 minutes
  • GABA receptor isoforms change and become
    ineffective
  • Phenobarb, benzodiazepines work on GABA

20
STATUS EPILEPTICUS ANTICONVULSANT SEQUENCE
RATIONALE
  • VA SE Cooperative Study Group
  • NEJM 17Sep98339(12)792-8
  • Efficacy GTC SE 384 pts
  • lorazepam 64.9
  • phenobarbital 58.2
  • diazepam then phenytoin 55.8
  • phenytoin 43.6
  • Key points
  • Administer meds early and quickly
  • Protocol more effective, regardless of sequence
    (meds given quicker)
  • Benzos and phenobarb effective early
  • PHT, VPA, LVT effective later
  • Midazolam for failure

21
Suggested protocol
  • Lorazepam 0.1 mg/kg IV or PR
  • Repeat lorazepam 0.1 mg/kg in 5 minutes (draw up
    after 3 minutes)
  • Phenytoin/fosphenytoin 20 mg/kg in 5 minutes
  • Phenobarb 20 mg/kg in 5 minutes
  • Phenytoin/fosphenytoin 10mg/kg in 5 minutes

22
  • While you are working through your anticonvulsant
    treatment, what diagnostic work-up are you
    considering?

23
STATUS EPILEPTICUS -- EVALUATION
  • HP
  • Blood lytes, glucose, Ca, BUN, CBC, ABG, LFT,
    AED level, tox chromatography
  • Urine toxicology screen
  • Febrile culture blood, urine, CSF plus CXR
  • CT or MRI if no etiology or have suspicion

24
  • If he fails to respond to initial meds, what else
    should you think about?

25
Considerations for SE AED failure
  • Phenytoin level gt35
  • CBZ or PHT for primary generalized sz
  • Symptomatic (glu or Na abnl, drug or med, etc)
  • lt18 m/o B6 dependency
  • lt6 m/o Folinic acid responsive epilepsy

26
Refractory STATUS EPILEPTICUS
  • Definition
  • gt 60 minutes, or failed 2 anticonvulsants
  • Rx options to produce burst suppression EEG
  • Midazolam
  • 0.2 mg/kg bolus
  • then 1-10 ?g/kg/min
  • Pentobarb
  • 15 mg/kg bolus
  • then 1-5 mg/kg/hr
  • propofol contraindicated in children
  • can cause fatal myocardial failure, metabolic
    acidosis, hypoxia, rhabdo

27
  • His seizure resolves after 3 doses of Ativan, and
    2 doses of Fosphenytoin. After two hours he is
    still post-ictal. What should you think about?

28
STATUS EPILEPTICUS -- TYPES
  • Generalized
  • non-convulsive
  • convulsive
  • Partial
  • Psychogenic

29
NON-CONVULSIVE GENERALIZED STATUS
  • Spike-wave stupor
  • mental dullness, confusion, clumsiness
  • slow or monosyllabic speech
  • EEG diagnosis
  • diazepam universally effective

30
PSYCHOGENIC STATUS
  • 25-50 also have epileptic seizures
  • differentiating from status
  • non-noxious stimuli
  • noxious stimuli
  • presentation
  • EEG

31
  • Why is there a sense of urgency when treating
    status epilepticus?

32
STATUS EPILEPTICUS -- SEQUELAE
  • 3 factors
  • 1) damage by acute insult
  • 2) systemic stress from motor convulsions
  • - exhaustion of metabolic supply
  • 3) injury from repetitive electrical discharges
    in CNS and glutamate release

33
STATUS EPILEPTICUS -- SYSTEMIC STRESS
  • Cardiovascular--rate, rhythm, BP
  • Respiratory--insufficiency, pulmonary edema
  • Biochemical
  • acidosis, BUN, potassium
  • glucose, sodium, hypoxemia
  • Autonomic -- fever, secretions
  • Renal -- rhabdomyolosis, ARF

Shorvon 2001
34
STATUS EPILEPTICUS -- MORBIDITY MORTALITY
  • 3-15 mortality
  • 5-40 residual neurologic deficit
  • most closely related to etiology of status
  • Maytal study (children)
  • Idiopathic, noncompliance, febrile status had
    NO MM

35
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