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24 Cards in this Set

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what is status epilepticus?
single unremitting seizure 5 to 30 minutes long or a frequent clinical seizures w/o interictal return to baseline
what is refractory status epilepticus?
ongoing seizures following first- and second-line drug therapy
what are some of the more common predisposing factors to status epilepticus?
- antiepileptic drug noncompliance or discontinuation
- withdrawal syndrome assoc. with stopping alcohol, barbiturates, baclofen, or benzo's
- acute structural injury (eg. encephalitis, tumor, stroke, trauma, anoxia, subarachnoid hemorrhage)
- remote or longstanding structural injury
- metabolic abnormalities
- use of or o/d with drugs that lower seizure threshold
- chronic epilepsy
what metabolic disturbances can cause status epilepticus?
hypoglycemia
hepatic encephalopathy
uremia
pyridoxine deficiency
hyponatremia
hypocalcemia
hypomagnesemia
what is mortality rate for adults presenting with first status epilepticus?

how about for status after cerebral anoxia?
20%

69% to 81%

note: underlying etiology is most important factor
what does neuronal death look like in 30 to 60 minutes of continuous seizure activity? ie. name the hallmark finding.
cortical laminar necrosis on brain MRI
what are the 2 best tests to diagnose status epilepticus?
neuro exam and EEG
what are the 3 most common forms of status epilepticus?
1. simple partial (focal motor seizures, focal sensory symptoms, or cognitive sx w/o LOC)
2. complex partial (same as #1, but with LOC)
3. generalized tonic-clonic (always assoc. with impaired consciousness)
what are the 4 main drugs used to treat status epilepticus?
1. benzodiazepines
2. phenytoin (or fosphenytoin)
3. barbiturates
4. propofol
what is the first line tx for status epilepticus? how do they work?
benzo's: diazepam, lorazepam, midazolam

increase Cl- conductance in CNS GABA(A) receptors and thus decrease neuronal excitability
which is the first choice benzo to treat status epilepticus?
diazepam: hi lipid solubility and crosses BBB quickly; affects seizure activity in 10 to 20 sec.

lorazepam takes longer to work, but also stays longer
When comparing lorazepam vs. phenytoin vs. diazepam plus phenytoin vs. phenobarbital, which was most effective in terminating generalized convulsive status epilepticus w/in 20 min and keeping a seizure-free state for 60 min?
lorazepam
when do you use midazolam in status epilepticus?
continuous infusion for refractory status w/ minimal cardio side-effects
what is good about tx of status epilepticus with phenytoin? what should you watch for?
prevents recurrence of status for a longer time

monitor cardiac variables to check for brady- or tachyarrhythmias
what is better about fosphenytoin vs. phenytoin?
less local irritation at infusion site
what are the most useful barbiturates in status?
phenobarbital and pentobarbital
how do barbiturates work?
like benzo's, they bind to GABA(A) receptors, amplifying action of GABA by extending GABA-mediated Cl- channel openings; boosts hyperpolarization
if phenobarbital is so great, why not use it as first-line tx?
higher risk of hypoventilation and hypotension than benzo's or phenytoin

has a very long half-life (87 to 100 hrs)
when is pentobarbital used in status?
when it's refractory status.
vasopressors are often required when treating status w/ which drug?
pentobarbital
what is propofol? what are some problems with it?
it's a hindered phenolic compound

hypotension and respiratory depression
why is the use of valproic acid limited in tx of status?
FDA allows only slow infusion rates;
what would initial therapy look like in status?
1. give 0.02 to 0.03 mg/kg of lorazepam and wait a minute to check effect
2. if no effect, keep giving lorazepam up to 2mg/min
3. start another IV catheter and start giving phenytoin (or fosphenytoin) - this will help prevent recurrence
4. EEG monitoring is ideal
what are primary drugs for refractory status epilepticus?
phenobarbital
pentobarbital
midazolam
propofol