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31 Cards in this Set

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Status Epilepticus definition.
Seizure for more than 5 min
Technically longer than 30 min
but seizures that last longer than 5 minutes are less likely to terminate and you want to treat
Clinical Manifestations.
Limb convulsions
Longer than 5 minutes
A/O x 0
Persistent upper gaze
Incontinence
Tachycardia, Hypertension, Tachypnea, Diaphoresis
Potential etiologies.
Head trauma
Subtherapeutic drug levels
Goals in status epilepticus.
Termination of seizure - If the convulsions stop but they don't regain mental status, they could be having non-convulsive status epilepticus where brain activity is still abnormal
Prevent recurrence (electrolyte abnormalities)
Reduce adverse effects
Stabilize ABC's
Non-pharmacologic therapy
Assess and control airway, breathing and circulation
Make sure iv lines are not pulled out
Initial pharmacotherapy plan in status epilepticus
Thiamine - to prevent wernicke's encephalopathy
D5W - to cover for possible hypoglycemia
Fluids
Benzodiazepine
all IV
Which benzodiazepine is the best choice?
Diazepam - Fast onset but very short acting so not good for recurrence (DOA 30 min - You'd want to give a long acting anticonvulsant also like phenytoin
Lorazepam - Longer duration of action - This is the drug of choice and has a greater affinity to the receptor. Don't have to give Phenytoin with this agent
Midazolam - Very short acting - Must be administered continuous IV infusion which would be a problem with no IV access
What is the dose of Lorazepam?
4 m IVP x 1
May repeat in 5 min if no response
Max dose 8 mg
Which agent is good if the patient needs the agent IM (thrashing about)
Midazolam 200 mcg/kg IM
Monitoring
ABG
Chem 7
CBC
Consciousness
Convusions
Benzo side effects (sedation, respiratory depression)
To find out the underlying cause
If initial therapy does not work, what would you give?
Must think of infusion rate
Phenytoin or Fosphenytoin
Phenytoin max rate 50 mg/min (25 mg/kg in elderly)
Fosphenytoin max rate 150 mg/min
Phenytoin LD 10-20 mg/kg (lower for elderly, higher for obese)
May repeat 5 mg/kg if unresponsive to initial dose
Fosphenytoin - Dose and infusion rate related paresthesia and pruritis of the face and groin
Why does phenytoin have a lower max infusion rate?
Vehicle is propylene glycol
Hypotension and arrhythmia's related to too-rapid infusion
This is most likely to occur in elderly patient with cardiac disease or critically ill patients with low blood pressure
Fosphenytoin is a prodrug with fewer BP and ECG changes
When do you want to check the phenytoin level after infusion has ended?
2 hours
Why is phenytoin used as a second line agent?
Phenytoin works in up to 90% of patients
Infused over such a long time and works so slowly, so that is why it is used as a second line agent after a benzo.
Monitoring.
Vital signs
ABGs
ECG
Phenytoin level 2 hours after infusion and right before first loading dose
You need to start a loading dose in 12-24 hours (not immediately)
What can you do if the phenytoin doesn't work?
You can give an additional 5 mg/kg of phenytoin or fosphenytoin equivalents
or
IV Phenobarbital
Things you can do if the status epilepticus is still going on for more than 60 min
IV Phenobarbital bolus every 1 hour until seizures stop
IV Valproate bolus followed by infusion
IV Midazolam bolus followed by infusion
IV Pentobarbital
IV Propofol
When would you want to use Phenobarbital over Phenytoin?
Patients who
Failed benzo + phenytoin
Have a phenytoin allergy
Have cardiac conduction abnormalities
What are the adverse events of phenobarbital?
CNS Depression
Respiratory Depression
Hypotension
***Controls seizures within minutes and there is no max dose***
What would you do if the patient had no IV access?
IM Midazolam
If the patient was on clonazepam at home?
Need a higher dose but respect maximum doses.
If the patient had a history of atrial fibrillation?
Phenobarbital
How would you adjust the patients medication therapy if they had not been on phenytoin prophylaxis?
You'd wanna go higher if the patient was obese
Phenytoin half life is about 24 hours
So check levels in 3-5 days
You need to look at albumin when assessing Phenytoin levels. What is the equation to adjust serum phenytoin?
Adjusted concentration = measured total concentration/ [(0.2 x albumin) + 0.1]
What is the Phenytoin - Fluconazole interaction?
Fluconazole is a 2C9 inhibitor, phenytoin is a substrate
Fluconazole increases the serum level of phenytoin
What is the concern with giving Zonisamide?
It has a sulfa moiety
Sulfa allergy
Carbamazepine is an inducer and an auto-inducer.
It can decrease the levels of other drugs as well as its own levels.
Phenytoin
Substrate of 2c9, 2c19
Inducer of 3a, 2c
Carbamazepine
Substrate 3a4 1a2 2c8
Inducer 1a2 2c 3a
AED's that are renally eliminated
Gabapentin
Pregabalin
Levetiracetamen
Topiramate