Appendix C Guidelines for treating status epilepticus in adults and children

Transcription

1 Appendix C Guidelines fr treating status epilepticus in adults and children 1.1 Treating cnvulsive status epilepticus in adults General measures 1st stage (0 10 minutes) Secure airway and resuscitate Administer xygen Assess cardirespiratry functin Establish intravenus access Early status 2nd stage (0 30 minutes) Institute regular mnitring Cnsider the pssibility f nn-epileptic status Emergency AED therapy Emergency investigatins Administer glucse (50 ml f 50% slutin) and/r intravenus thiamine (250 mg) as high ptency intravenus Pabrinex if any suggestin f alchl abuse r impaired nutritin Treat acidsis if severe 3rd stage (0 60 minutes) Establish aetilgy Alert anaesthetist and ITU Identify and treat medical cmplicatins Pressr therapy when apprpriate 4th stage (30 90 minutes) Transfer t intensive care Establish intensive care and EEG mnitring Initiate intracranial pressure mnitring where apprpriate Initiate lng-term, maintenance antiepilepsy drug therapy Established status Refractry status Emergency investigatins Bld shuld be taken fr bld gases, glucse, renal and liver functin, calcium and magnesium, full bld cunt (including platelets), bld cltting, antiepilepsy drug levels; 5ml f serum and 50ml f urine samples shuld be saved fr future analysis, including txiclgy, especially if the cause f the status epilepticus is uncertain. Chest radigraph t evaluate pssibility f aspiratin. Other investigatins depend n the clinical circumstances and may include brain imaging, lumbar puncture. Mnitring Regular neurlgical bservatins and measurements f pulse, bld pressure, temperature. ECG, bichemistry, bld gases, cltting, bld cunt, drug levels. Patients require the full range f ITU facilities and care shuld be shared between anaesthetist and neurlgist. EEG mnitring is necessary fr refractry status. Cnsider the pssibility f nn-epileptic status. In refractry status epilepticus, the primary endpint is suppressin f epileptic activity n the EEG, with a secndary endpint f burst-suppressin pattern (i.e. shrt intervals f up t 1 secnd between bursts f backgrund rhythm). 1

2 1.1.1 Emergency antiepilepsy drug treatment fr cnvulsive status epilepticus Premnitry stage (pre-hspital) Diazepam mg given rectally, repeated nce 15 minutes later if status cntinues t threaten, r midazlam 10 mg given buccally If seizures cntinue, treat as belw Early status Lrazepam (i.v.) 0.1 mg/kg (usually a 4 mg blus, repeated nce after minutes; rate nt critical) Give usual AED medicatin if already n treatment Fr sustained cntrl r if seizures cntinue, treat as belw. Established status Phenytin infusin at a dse f mg/kg at a rate f 50 mg/minute r fsphenytin infusin at a dse f mg phenytin equivalents (PE)/kg at a rate f mg PE/minute and/r Phenbarbitne blus f mg/kg at a rate f 100 mg/minute Refractry status* General anaesthesia, with ne f: prpfl (1-2mg/kg blus, then 2-10mg/kg/hur) titrated t effect. midazlam ( mg/kg blus, then mg/kg/hur) titrated t effect. thipentne (3-5mg/kg blus, then 3-5mg/kg/hur) titrated t effect; after 2-3 days infusin rate needs reductin as fat stres are saturated. Anaesthetic cntinued fr hurs after the last clinical r electrgraphic seizure, then dse tapered *In the abve scheme, the refractry stage (general anaesthesia) is reached 60/90 minutes after the initial therapy. This scheme is suitable fr usual clinical hspital settings. In sme situatins, general anaesthesia shuld be initiated earlier and, ccasinally, shuld be delayed. Experience with lng-term administratin (hurs r days) f the newer anaesthetic drugs is very limited. The mdern anaesthetics have, hwever, imprtant pharmackinetic advantages ver the mre traditinal barbiturates. Lng term antiepilepsy drug therapy Lng-term, maintenance, antiepilepsy therapy must be given in parallel with emergency treatment. The chice f drug depends n previus therapy, the type f epilepsy, and the clinical setting. Any pre-existing AED therapy shuld be cntinued at full dse, and any recent reductins reversed. 2

3 If phenytin r phenbarbitne has been used in emergency treatment, maintenance dses can be cntinued rally r intravenusly guided by serum level mnitring. Other maintenance AEDs can be started als, with ral lading dses. Care needs t be taken with nasgastric feeds, which can interfere with the absrptin f sme AEDs. Once the patient has been free f seizures fr hurs and prvided that there are adequate plasma levels f cncmitant antiepilepsy medicatin, then the anaesthetic shuld be slwly tapered. 1.2 Guidelines fr treating status epilepticus in children Treating cnvulsive status epilepticus In 2000, a cnsensus guideline was prduced by the Status Epilepticus Wrking Party f the British Paediatric Neurlgy Assciatin 1. This was based n a systematic review f paediatric status epilepticus evidence, which identified nly tw randmised cntrlled trials. The guideline was therefre based n bth evidence (paediatric and adult where apprpriate) and clinical experience. The guideline is primarily designed fr the A&E department r the hspital paediatric ward. The investigatin f the cause f status epilepticus is nt addressed. Generalised cnvulsive (tnic-clnic) status epilepticus is defined as a generalised cnvulsin lasting 30 minutes r lnger, r repeated tnic-clnic cnvulsins ccurring ver a 30 minutes perid withut recvery f cnsciusness between each cnvulsin. Hwever, the guideline stated that fr practical purpses, the apprach t the child wh presents with a tnic-clnic cnvulsin lasting mre than 5 minutes shuld be the same as the child wh is in established status t stp the seizure and t prevent the develpment f status epilepticus. 1 The cnsensus prtcl can be seen in Figure 1. 3

4 Figure 1 Treatment guideline fr an acute tnic-clnic cnvulsin including established cnvulsive status epilepticus 1. Mdified frm Appletn Permissin sught and awaiting respnse. Airway Breathing Circulatin Give high flw xygen Measure bld glucse Cnfirm epileptic seizure 1.1 IMMEDIATE ACCESS NO IV ACCESS 1. LORAZEPAM 0.1 MG/KG IV 1. DIAZEPAM 0.5 MG/KG PR (Give ver secnds) seizure cntinuing at 10min IV ACCESS seizure cntinuing at 10min. 2. LORAZEPAM 0.1 MG/KG IV 2. PARALDEHYDE 0.4 ML/KG PR (Give ver secnds) (Give with sme vlume f live il) seizure cntinuing at 10 min seizure cntinuing at 10 min CALL FOR SENIOR HELP 3. PHENYTOIN 18 MG/KG IV OVER 20 MINUTES OR If already n PHENYTOIN give PHENOBARBITONE 20 MG/KG IV OVER 10 MINUTES (use intrasseus rute if still n IV access) AND PARALDEHYDE 0.4 ML/KG PR + SAME VOLUME OF OLIVE OIL IF NOT ALREADY GIVEN AND CALL ON-CALL ANAETHETIST OR INTENSIVE CARE MEDIC When the prtcl is initiated it is imprtant t cnsider what pre-hspital Seizure cntinues 20 minutes after cmmencing step 3 treatment has been received and t mdify the prtcl accrdingly. 4. RAPID SEQUENCE INDUCTION OF ANAESTHESIA USING THIOPENTONE 0.4 MG/KG IV TRANSFER TO INTENSIVE CARE UNIT 4

5 1.3 Nn-cnvulsive status epilepticus in adults and children Suggested by GDG This is less cmmn than tnic-clnic status epilepticus. Treatment fr nncnvulsive status epilepticus is less urgent than fr cnvulsive status epilepticus. Treatment shuld be cnsidered as fllws: Maintenance r reinstatement f usual ral AED therapy Use f intravenus benzdiazepines under EEG cntrl, particularly if the diagnsis is nt established Referral fr specialist advice and/r EEG mnitring Reference List 1. Appletn R, Chnara I, Martland T, Phillips B, Sctt R, Whitehuse W. The treatment f cnvulsive status epilepticus in children. The Status Epilepticus Wrking Party, Members f the Status Epilepticus Wrking Party. Arch.Dis.Child 2000;83: