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A single seizure ≥5 minutes 任何一次發作超過 5 分鐘
or two or more seizures without recovery of consciousness between seizures
2 次發作中意識沒有回到 baseline
但沒回到 baseline 也可能是 post ictal phase
- Tongue biting, convulsion, incontinence
- 身體眼睛不同邊, 不太有 oral 咀嚼動作,
不會有 purpose movement (例如抓著欄杆)
r/o syncope, chillness, other movement disorder
The goal of treatment is seizure control as soon as possible
and within 30 minutes of presentation
Do not attempt lumbar puncture during status epilepticus.
If bacterial meningitis or encephalitis is suspected clinically,
then immediately start empiric antibiotic or antiviral therapy.
0 - 5 mins : 準備觀察期
- Vital signs, Conscious : On monitor
- Airway 氣道暢通 : Position 側躺 ,Oral/nasal airway
- Breathing 給氧 : O2
- Circulation 維持循環 : IV
F/S < 60 : D50W + Vit. B1 100mg (Max : 500 mg)
- Lab :
Sugar, CBC/DC, Electrolyes 鈉鉀鈣鎂
Liver function, renal function
CK, Ammonia, lactate
VBG, 癲癇藥物濃度, Alcohol, drug screen
- Past hx, Neurologic signS, PE : Meningismus
- Lumbar puncture：
雖然不是每個病人都要 puncture
但記得考慮 CNS infection
- Brain CT：
如果第一次發生癲癇或是有History
但是型式改變了那 MRI 是最好的選擇
但是為了快速(怕出血)往往先做 CT
- EEG
癲癇原因 - MIT
- M : Metabolic - 尿毒, 血糖, 肝衰竭, 電解質
- I : Infection, Infarction - 腦炎, 腦膜炎, 腦梗塞
- T : Toxin, Trauma, Tumor
藥物中毒, 藥物沒吃, 藥物戒斷, 酒精戒斷
Brain tumor
第一期
1. Lorazepam ( Anxican )
0.1 mg/kg/dose IV, max 4 mg/dose, may repeat once
2 mg / amp, 兩支 IV, 可以再給一次
2. Midaozlam ( Domicum )
10 mg IM in pt > 40kg, single dose
DORMICUM★ 5mg/1mL/amp : 兩支 IM
3. Diazepam ( Vanolin, Valium )
0.2 mg/kg/dose IV, max 10 mg/dose, may repeat once
Dupin★10mg/2mL/amp : 一支 IV, 可以再給一次
Domicum 2 amp IM / Diazepem 1 amp IV
IV lorazepam (2 - 4 mg) and IV diazepam (5 - 10 mg)
have equal efficacy in controlling status epilepticus
IM midazolam was determined to be as safe and effective as IV lorazepam.
However, IV lorazepam is still considered
the initial agent of choice if IV access is available.
第二期
Valproic acid (Depakine)
40 mg/kg iv single dose, 不超過 3000mg
通常都給個 30mg/kg
Depakine(400mg/amp), 大概 70kg 要給 5 amp, 每分鐘推 1 amp
明顯肝功能不好, 肝硬化 ...
不能使用, 其他一般狀況不需要特別驗肝功能
WFH : 800mg STAT + 400mg Q8H
Serious side effects : hepatic failure and pancreatitis
The dose is 20 - 40 mg/kg IV
Levetiracetam = Keppra
500mg/amp
WFH : 1500mg STAT + 500mg Q12H
few interactions and side effects
The dose is 20 - 60 mg/kg IV
Administration for status epilepticus,
it is rapidly gaining favor as a first-line drug for established status epilepticus
Fosphenytoin or phenytoin; levetiracetam; valproate; or lacosamide
started within 20 minutes of diagnosis
第三期
後線藥物呼吸抑制太強
常需要 intubation and transfer to Neuro ICU
Recommendations include propofol, midazolam, and barbiturates such as phenobarbital or pentobarbital given as infusions.
All of these agents can lead to hypotension,
sometimes requiring concomitant vasopressor use, and frequently require intubation.
Midazolam and propofol have the advantage over barbiturates of having a shorter half-life and rapid clearance
propofol and midazolam infusions as first- and second-line agents
Ketamine may also be considered as a third-line agent in refractory status epilepticus.
Ketamine can be administered as a bolus dose of 0.5 - 4.5 mg/kg or as an infusion up to 5 mg/kg/h.
Midazolam 0.2 mg/kg IV (50 kg 約 10 mg) then infusion
Midazolam pump for status epilepticus (12059399)
【Dilution/Conc】 50 mg midazolam in D5W/NS 40 mL, concentration 1 mg/mL
【Loading dose】 0.2 mg/kg IV x1
【Rate】 After loading dose, start IVD at 0.05 mg/kg/hr, range 0-2 mg/kg/hr
【Goal】 RASS -5~-4 and Cessation of electrographic seizures or burst suppression
【Taper】Decrease infusion rate by 0.01 mg/kg/hr q1-2h as needed
【Others】
Breakthrough seizure while on continuous infusion:
Give 0.1-0.2 mg/kg IV x1 and then increase IVD rate by 0.05-0.1 mg/kg/hr q3-4h as needed)
60kg : 12ml loading, start run 3 ml/hr, up to 120 ml/hr
decrease 0.6 ml/hr q1-2h, Breakthrough give 6-12ml then increase 3 ml/hr
Propofol for Status epilepticus
【 Dilution/Conc】Pure 1000 mg propofol, concentration 10 mg/mL;
change propofol tubing and infusion bottle Q12H
【Loading dose】 1-2 mg/kg IV x1
【Rate】 After loading dose, start IVD at 20 mcg/kg/min, range 0-200 mcg/kg/min
【Monitor】Check triglyceride at baseline, 48 h later, and Q3D thereafter
【Goal】RASS -5~-4 for status epilepticus and cessation of electrographic seizures or burst suppression
【Other】
Breakthrough seizure while on continuous infusion:
Give 1 mg/kg IV x1, and then increase IVD rate by 5-10 mcg/kg/min q5min as needed)
Propofol started as an infusion at typical rates of 2 to 10 milligrams/kg/h
用了一種第一線用藥, 一種第二線用藥
還不能在 30~60 分鐘內停止
應考慮盡早使用麻醉藥品 (midazolam, propofol 或 pentobarbital)
治療反應不佳的重積性癲癇
應考慮監測 EEG 作為調整劑量依據
Monitor seizure complications !
無限抽下去就不只是腦的問題了 !
- Hypoxia
- Lactate acidosis
- Rhabdomyolysis
- Hypotension
Hypotension, Hypoxia, Metabolic acidosis, Hyperthermia, Hypoglycemia,
Cardiac dysrhythmias, and pulmonary edema frequently develop
In nonconvulsive status epilepticus
the patient is comatose or has fluctuating abnormal mental status or confusion,
but no overt seizure activity is present.
The diagnosis is challenging and is typically made by EEG.
Findings suggestive of nonconvulsive status epilepticus
include a prolonged postictal period after a generalized seizure;
include a prolonged postictal period after a generalized seizure;
subtle motor signs such as twitching, blinking, and eye deviation;
fluctuating alterations in mental status; or unexplained stupor and confusion.
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