11

22

Status Epilepticus is defined as :

Continuous seizure activity lasting longer than 30 minutes or two or more sequential seizures without full recovery of consciousness

50% as a symptom of an undelying diseases

The remainder caused by complex febrile seizure and

idiopathic epilepsy

33

Management divided into 3 phases:Management divided into 3 phases:

1. Emergency Stabilization1. Emergency Stabilization

2. Anticonvulsant Therapy2. Anticonvulsant Therapy

3. Diagnostic Work-up3. Diagnostic Work-up

ManagementManagement To prevent or minimize the morbidityTo prevent or minimize the morbidity

and mortality resulting from SEand mortality resulting from SE

THE FIRST STEP IN MANAGINGTHE FIRST STEP IN MANAGING SESE IS ASSESING THE PATIENT’S IS ASSESING THE PATIENT’S

AIRWAY AND OXYGENATIONAIRWAY AND OXYGENATION

44

1. To prevent secondary hypoxic-ischemic brain injury1. To prevent secondary hypoxic-ischemic brain injury

2. Establish an adequate airway, ensure adequate 2. Establish an adequate airway, ensure adequate

oxygenation and ventilationoxygenation and ventilation

3. Establish venous (or intraosseous) access and ensure 3. Establish venous (or intraosseous) access and ensure

effective circulating blood volume and perfusion pressureeffective circulating blood volume and perfusion pressure

4. Obtain blood for glucose determination4. Obtain blood for glucose determination

Emergency Stabilization (ABC’s)Emergency Stabilization (ABC’s)I.

55

Emergency StabilizationEmergency Stabilization

5. Control fever5. Control fever

6. Pass a nasogastric tube; aspirate for toxicology6. Pass a nasogastric tube; aspirate for toxicology

7. Assess cardiorespiratory status after anticonvulsants7. Assess cardiorespiratory status after anticonvulsants

66

II. ANTICONVULSANT THERAPY 

A. Goals of Therapy1. Rapidly terminate seizure activity

2. Prevent recurrences of seizure and secondary injury

B. Route of anticonvulsants

These agents should be administered iv or io

Midazolam (MILOZR) is the only anticonvulsant that is

rapidly effective when given im, rectally, buccally

or nasally (5-10 minutes)

77

C. Benzodiazepines

1. Extremely rapid onset of action, short duration of

action

2. Include diazepam, midazolam, and lorazepam

3. Side effects: resp. depressions, sedation, and

hypotension

4. A second longer acting drug

(phenytoin/DILANTINR,

phenobarbital) prevent recurrence.

The anticonvulsan effects of lorazepam (ATIVANR)

last 6-12 hours, even 24-48 hours as the addition of

a longer acting drug may not be necessary,

(half life 2-3 hours versus 15 minutes for

diazepam).

88

D. Phenytoin (DILANTINR) 18 mg/kg iv 1. Effective for SE 2. To advantages over phenobarbital a. does not cause respiratory depression b. Causes much less sedation 3. Side effects: bradycardia and hypotension 4. Infused slowly (0,5-1 mg/kg/minute), max. 30 mg/kg up to 1000 mg BP and ECG should be monitor during infusion (hypotension and arrhythmias)

99

E. Phenobarbital 15-20 mg/kg iv 1. Effective anticovulsant, relative slow onset of action

2. Side effects: resp. depress., sedation, and

hypotension

3. If benzodiazepine followed by phenobarb.

may require intubation (respiratory depression)

4. Drug of chioce for neonatal SE

max. 30 mg/kg up to 600 mg

Thiopental induction dose 4-8 mg/kg for SE

It is not an effective long-term anticonvulsant.

Principal use in SE is to facilitate ventilation and

subsequent

management of cerebral oedema.

Other antiepileptic medication should be continued.

1010

ALGORITHM MANAGEMENT OF SEIZURE

Diazepam IV: 0,3 – 0,5 mg/kg orDiazepam PR: BW <10 kg: 0,5 mg/kg BW >10 kg: 0,3 mg/kg, orDiazepam PR: BW <10 kg: 5 mg BW >10 kg:10 mg

Seizure stop ? YES

Stop medication

NO

Diazepam IV : 0,3 – 0,5 mg/kg orDiazepam PR: BW <10 kg: 5 mg BW >10 kg: 10 mg(midazolam 0,05-0,1 mg/kg iv)Hypoglycemia: D25 2 ml/kgSeizure stop ? YES

Stop medication

NO

Repeat x 2 every 5 minMidazolam?

0-5 minutesA, B, C resuscitation

Vital signHemodynamic monitor

Brief historyNeurologic exam.Bloodwork (lab.)

5-10 minutes

1111

Seizure stop ?

NO10-15 minutes

Prolonged SeizureTend to SE

Airway - Breathing – CirculationSign of trauma/infection andFocal paresisAccess intravenous lineExamine: blood routine, glucose, electrolyte

Phenytoin 15-20 mg/kg iv bolus1 mg/kg/min

Seizure stop ?

NO YES

Phenobarbital 10-20 mg/kg IV (IM)

Seizure stop ?

12 hrs after initialPhenytoin 5-7 mg/kg iv

StatusEpilepticus

> 30 minutes

1212

Seizure stop ?

NO

Intubate PICU

Midazolam 0,05-0,3 mg/kg iv,then maintenace 0,05-2 mcg/kg/min.or Thiopental 4-8 mg/kg ivor Propofol 1-2 mg/kg ivRespiratory depression ventilatorMuscle relaxant/paralyze CFAM - EEG

YES

12 hrs after initial dosePhenobarbital 3-4 mg/kg im +Phenytoin 5-7 mg/kg iv

CFAM= cerebral function analysis monitoring

Refractory Seizure

1313

1414

A sudden severe increase in blood pressure to a level exceeding > 95th percentile for age

HYPERTENSIVE CRISIS

HYPERTENSIVE ENCEPHALOPAHTY

A set of symptoms including headache, convulsionand coma, associated with certain kidney diseases, pheochromocytoma, and drugs.

SBP or DBP > 99th percentile for age with evidence of impaired end organ perfusion

HYPERTENSIVE EMERGENCIES

SBP OR DBP > 95th Percentile for age on three measurements

HYPERTENSION

1515

AGE

MODERATE HYPERTENSION

(95TH-99TH %ILE)

SEVERE HYPERTENSION

(>99TH % ILE)

< 1 year

1-9 years

10-12 years

12-18 years

Systolic >110 Diastolic >75

Systolic >120 Diastolic >80

Systolic >125 Diastolic >82

Systolic >135 Diastolic >85

Systolic >120 Diastolic >85

Systolic >130 Diastolic >85

Systolic >135 Diastolic >90

Systolic >145 Diastolic >90

1616

Severe vasoconstriction causing ischemia to end

organs and excessive afterload for myocardium.

CNS effects: a. Encephalopathyb. Intracranial hemorrhage

Left ventricular failure with pulmonary edema

Acute renal failure

Retinopathy

1717

80-90% renal origin

1. Renal parenchymal or vascular disease

2. Vasculitis (e.g, SLE, polyarteritis nodosa)

3. Mineralocorticoid excess

a. Corticosteroid use

b. Adrenogenital syndromes

c. Cushing’s syndrome

4. Catecholamine excess: a. Neuroblastoma

b. Pheochromocytoma

5. Autonomic dysfunction

1818

1. Direct vasodilators or sympathetic inhibitors

2. Relieve symptoms of end organ ischemia

3. May need adrenergic blockade to prevent

reflex tachycardia

The goal of acute parenteral therapy: 20% reduction in (MAP)MAP = (diastolic+1/3 [systolic-diastolic]) or Systolic - 2 diastolic : 3

(25% BP reduction within 1hrs)

1919

Antihypertensive agentAntihypertensive agent

DRUG DOSE ROUTE COMMENTS

Nifedipine 0.25-0.5 mg/kg SL Predictable, can be drown up as liqiud from capsule for IV adm

Labetalol 0.1-0.25 mg/kg IV Slow IV push over 2 min, double every 10 min until effect is achieved (300mg total) then give last dose prn

Esmolol 500g/kg/min x 2min then 50g/kg/min

IV CI: in patients with asthma or who have received Ca++ channel blocker

Nitroprussid Hydralazine

0.5g/kg/min 0.1-0.5 mg/kg

IV

IV

Intra-arterial monitoring reguired

Diazoxide 0.1-0.5 mg/kg IV Repeat at 10-15 min intervals, causes hyperglycemia