EPILEPTICUS Dr. Mansi Shah, MD Medicine Definition
Clinical - Unremitting generalized convulsive seizure lasting longer than five minutes or Multiple bilateral convulsive seizures without an interictal return to the baseline level of consciousness. Focused 01. Past history of epilepsy
history
Recent/ongoing anti-seizure medications
02. Precipitating factors prior to seizure
& treatment response.
Acute illness, possible toxic exposure, trauma, recent heavy alcohol intake or cessation of chronic drinking, change in antiseizure medications 03. Medical comorbidities Steps of acute care
A B C D E positioning 100 % O2 2 large IV bore ·(Neurologic ·(Head to toe manoeuvres – left Bag & mask lines state) evaluation) lateral & SOS ventilation FLuid bolus -GCS Nasopharyngeal SOS RSI Vasopressors -Any obvious -trauma, sepsis, airways > Induce- SOS signs of head meningitis, oropharyngeal Propofol trauma, sepsis, encephalitis, or NM blockers - anisocoria or structural brain cEEG meningitis. lesion Assesment of vitals & Initial work up T, P, RR, BP, SpO2 & temperature. Point-of-care glucose - Hypoglycemia should be treated with 100 mg of thiamine and 50 mL of 50 percent dextrose solution. If IV access is not available, IM glucagon can be considered. Serum electrolytes with calcium, phosphorus, and magnesium – note - severe hyponatremia or hypocalcemia - refractory to antiseizure medication CBC & Liver function tests Serum antiseizure medication levels, if applicable Urine and blood toxicology Qualitative pregnancy test (urine or blood) in women of childbearing age Cardiac troponin and pyridoxine levels B6 levels Serum lactate - hypoperfusion or underlying infection. ABG - Metabolic acidosis - usually resolves without treatment once seizures are controlled. Intial therapy Diazepam Lorazepam Midazolam Rectal, intranasal IV IM, intranasal, or buccal Rectal; 0.2 mg/kg up 4 mg over 2-5 mins. IV 0.2 mg/kg over 2-5 to 20 mg for an adult (0.1 mg/kg) mins, max 2 mg/kg (same IV: Diazepam 0.15 (Dilute with equal vol NS, for RSI) mg/kg IV, max rate DNS or distilled water) Buccal 10mg (max 30mg) 5mg/min, up to 10 mg Continue at max 2 & Nasal spray (5 mg/0.1 per dose, undiluted mg/minute mL) - one spray (5 mg) in Ready to use No max accepted dose each nostril (10 mg) <20 mins (due to Need to formulate Ready to use redistribution into 4 to 12 hrs adipose tissue) Approximately 20% of patients develop refractory status epilepticus and require additional therapy A common reason for inadequate response - Inadequate dosing of benzodiazepine Failure of initial response – sign of poorer prognosis Success for "subtle" GCSE < "overt" GCSE. Second Rx: Antiseizure Medication
LEVETIRACETAM FOSPHENYTOIN PHENYTOIN VALPROATE
LOADING DOSE OF 20 LOADING DOSE OF 40
LODING DOSE OF 20 MG MG/KG AND INFUSED AT MG/KG AND INFUSED AT PHENYTOIN EQUIVALENTS 25 TO 50 MG/MINUTE A RATE OF 10 MG/KG PER (PE)/KG INFUSED AT 100 TO 150 MINUTE IN ADULTS MG PE/MIN, AN ADDITIONAL (MAXIMUM DOSE 3000 DOSE OF 5 TO 10 MG, MAX 30 USE SEPARTE LINE MG) MG/KG THAN BZD, PPT PURPLE GLOVE LOADING DOSE OF 60 SYNDROME MG/KG (MAXIMUM 4500 MG) INFUSED OVER 15 MINUTES Making a choice Ensure adequate therapeutic levels (if not give loading dose of phenytoin or valproate) for levetiracetam even without the levels (as overdosage is not a concern) Give a different drug for breakthrough seizures Efficacy: fosphenytoin, valproate, and levetiracetam are equally effective with similar adverse effects Preferred in Liver failure, Polypharmacy, avoid drug interactions, easiest transition to other long term anti-seizure medications - levetiracetam Cardiac monitoring pre-requisite for fosphenytoin or phenytoin till at least 15 minutes after the end of a (continues to be dephosphorylated into phenytoin) Phenytoin and fosphenytoin may intensify seizures caused by cocaine, other local anesthetics, theophylline. Valproate - useful as a nonsedating option for focal or myoclonic status epilepticus (MSE). Caution with concurrent administration of phenytoin as free phenytoin level often rises since both agents are highly protein-bound. Higher maintenance doses or shorter intervals between doses for patient on enzyme-inducing antiseizure medications. Risks of hepatic dysfunction, and coagulopathy (independent of hepatic dysfunction) are important considerations in patients with active bleeding or recent neurosurgical procedures. Second line drugs Refractory seizures a) Phenobarbital – Even though high doses Patients actively seizing at 30 minutes will control almost any seizure but will despite two initial doses of a cause substantial sedation with reduction benzodiazepine and administration of of blood pressure and respiration. one or two other antiseizure medication Initial doses of phenobarbital 20 mg/kg loads, preparation for a continuous infused at a rate of 30 to 50 mg/minute infusion of midazolam, propofol, or Careful monitoring of respiratory and pentobarbital should begin. cardiac status is mandatory. At this stage, the patient will require Intubation is often necessary in order to endotracheal intubation and mechanical provide a secure airway and minimize the and transfer to an ICU with continuous risk of aspiration EEG (cEEG) monitoring. b) Lacosamide – 200 to 400 mg IV bolus, well tolerated and similar efficacy Rarely, serious second-degree and complete atrioventricular blocks Prior baseline electrocardiogram and during treatment watch for PR prolongation. Post ictal monitoring Prolonged postictal recovery – due to sedation due to medications and the continuation of (nonconvulsive) seizures. Monitor by cEEG – In about 15% patients have nonconvulsive status epilepticus in comatose state. The EEG pattern was focal or focal with secondary generalization in most patients. Very high mortality. Neurologic assessment - repeat a full neurologic examination Neuroimaging - suspected focal onset or those not recovering as expected, a head CT (emergency) or magnetic resonance imaging (MRI, better yield) should be obtained once seizures are controlled. Lumbar puncture – If clinical presentation is suggestive of an acute infection, there is a history of a malignancy or concern for leptomeningeal metastases. Note - Prolonged seizure itself can cause cerebrospinal fluid pleocytosis and should only be performed only after a space-occupying brain lesion has been excluded by appropriate brain imaging studies; blood cultures should be obtained and empiric antimicrobials should be started prior to brain imaging if there is concern for infection. THANK YOU VERY MUCH! Dr. Mansi Shah
