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Yazid Dimyati
Child Neurology Division
Department of Child Health, Medical Faculty
University of Sumatera Utara, H Adam Malik Hospital Medan
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▪ Status epilepticus (SE) presents in a multitude of
forms, dependent on etiology and patient age
(myoclonic, tonic, subtle, tonic-clonic, absence,
complex partial etc.)
Reviewed in: Lowenstein DH. It's time to revise the definition of status epilepticus. Epilepsia
1999;40(1):120-2.
Revised Definition
▪ Fever 36%
▪ Medication change 20%
▪ Unknown 9%
▪ Metabolic 8%
▪ Congenital 7%
▪ Anoxic 5%
▪ Other (trauma, vascular, 15%
infection, tumor, drugs)
▪ Antibiotics ▪ Psychopharmaceuticals
▫ Penicillins ▫ Antihistamines
▫ Isoniazid ▫ Antidepressants
▫ Metronidazole ▫ Antipsychotics
▪ Anesthetics, narcotics ▫ Phencyclidine
▫ Halothane, enflurane ▫ Tricyclic antidepressants
▫ Cocaine, fentanyl
▫ Ketamine
Mortality
▪ Adults 15 to 22%
▪ Children 3 to 15%
Life
Temporary
threatening
systemic Death
systemic
changes
changes
Duration of seizure
Respiratory
▪ Rare complication of SE
in children
▪ Likely occurs as
consequence of marked
increase of pulmonary
vascular pressure during
SE
▪ Respiratory
▪ Lactic
▫ Impaired tissue oxygenation
▫ Increased energy expenditure
Hemodynamics
▪ Sympathetic
overdrive
▫ Massive catecholamine / ● Exhaustion
autonomic discharge
❖ Hypotension
▫ Hypertension
❖ Hypoperfusion
▫ Tachycardia
▫ High CVP
0 min 60 min
Cerebral blood flow - Cerebral O2 requirement
▪ Hyperdynamic
phase
O2 requirement
▫ CBF
▪ Exhaustion phase
▫ CBF drops as
Blood flow hypotension sets in
▫ Autoregulation
Blood pressure
exhausted
Hyperdynamic Exhaustion ▫ Neuronal damage
Seizure duration ensues
▪ Hyperdynamic
phase
▫ Hyperglycemia
Glucose
▪ Exhaustion phase
SE ▫ Hypoglycemia
develops
▫ Hypoglycemia
appears earlier in
30 min presence of hypoxia
SE + hypoxia
▫ Neuronal damage
ensues
Seizure duration
▪ Labs
▫ Na, Ca, Mg, PO4 , glucose
▫ CBC
▫ Liver function tests, ammonia
▫ Anticonvulsant drug level
▫ Toxicology
Initial investigations
▪ Lumbar puncture
▫ Always defer LP in unstable patients, but never
delay antibiotic/antiviral treatment if indicated
▪ CT scan
▫ Indicated for focal seizures or focal deficit or focal
EEG, history of trauma or bleeding disorder
▪ Rapid acting
plus
▪ Long acting
Anticonvulsants - Rapid acting
▪ Benzodiazepines
▫ Lorazepam 0.1 mg/kg i.v. over 1-2 minutes
▫ Diazepam 0.2 mg/kg i.v. over 1-2 minutes
▪ Lorazepam ▪ Diazepam
▫ Low lipid solubility ▫ High lipid solubility
▫ Action delayed 2 minutes ▫ Thus very rapid onset
▫ Anticonvulsant effect 6-12 ▫ Redistributes rapidly
hrs ▫ Thus rapid loss of
▫ Less respiratory depression anticonvulsant effect
than diazepam ▫ Adverse effects are
persistent:
Hypotension
▪ Midazolam Respiratory depression
▫ May be given i.m.
Benzodiazepine - Rectal
▪ Rectal diazepam
▪ Diazepam IV
Benzodiazepine - Intramuscular
▪ Intramuscular midazolam
▫ 0.2 mg/kg i.m.
▫ Aqueous solution is rapidly absorbed,
anticonvulsant effect begins after 2 minutes
▪ Intramuscular lorazepam
▫ Can be given, but lacks water solubility, thus later
onset than midazolam
Chamberlain JM. Pediatr Emerg Care 1997;13(2):92-4.
Towne AR. J Emerg Med 1999;17(2):323-8.
Anticonvulsants - Long acting
▪ Phenytoin ▪ Fosphenytoin
▫ 20 mg/kg i.v. over 20 min ▫ 20 mg PE/kg i.v. over 5-7 min
PE = phenytoin equivalent
▪ Phenobarbital
▫ 20 mg/kg i.v. over 10 - 15 min
▫ Onset 15-30 min
▫ May cause hypotension, respiratory depression
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