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Konvulsi dan hipertensi pada Anak

Konvulsi dan hipertensi pada Anak

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Published by Taufik Abidin

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Published by: Taufik Abidin on Mar 07, 2009
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01/29/2013

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Status Epilepticus is defined as :
Continuous seizure activity lasting longer than 30 minutes or two or more sequential seizures without full recovery of consciousness 50% as a symptom of an undelying diseases The remainder caused by complex febrile seizure and idiopathic epilepsy
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Management
To prevent or minimize the morbidity and mortality resulting from SE

Management divided into 3 phases: 1. Emergency Stabilization 2. Anticonvulsant Therapy 3. Diagnostic Work-up THE FIRST STEP IN MANAGING SE IS ASSESING THE PATIENT’S AIRWAY AND OXYGENATION
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I.

Emergency Stabilization (ABC’s)

1. To prevent secondary hypoxic-ischemic brain injury 2. Establish an adequate airway, ensure adequate oxygenation and ventilation 3. Establish venous (or intraosseous) access and ensure effective circulating blood volume and perfusion pressure 4. Obtain blood for glucose determination

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Emergency Stabilization
5. Control fever 6. Pass a nasogastric tube; aspirate for toxicology 7. Assess cardiorespiratory status after anticonvulsants

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II. ANTICONVULSANT THERAPY
A. Goals of Therapy
1. Rapidly terminate seizure activity 2. Prevent recurrences of seizure and secondary injury

B. Route of anticonvulsants
These agents should be administered iv or io

Midazolam (MILOZR) is the only anticonvulsant that is rapidly effective when given im, rectally, buccally or nasally (5-10 minutes)
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C. Benzodiazepines
1. Extremely rapid onset of action, short duration of

action 2. Include diazepam, midazolam, and lorazepam 3. Side effects: resp. depressions, sedation, and hypotension 4. A second longer acting drug (phenytoin/DILANTINR, phenobarbital) prevent recurrence. The anticonvulsan effects of lorazepam (ATIVANR) 7

D. Phenytoin (DILANTINR) 18 mg/kg iv
1. Effective for SE 2. To advantages over phenobarbital a. does not cause respiratory depression b. Causes much less sedation 3. Side effects: bradycardia and hypotension 4. Infused slowly (0,5-1 mg/kg/minute), max. 30 mg/kg up to 1000 mg BP and ECG should be monitor during infusion (hypotension and arrhythmias)

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E. Phenobarbital 15-20 mg/kg iv
1.

Effective anticovulsant, relative slow onset of action

2. Side effects: resp. depress., sedation, and hypotension 3. If benzodiazepine followed by phenobarb. may require intubation (respiratory depression) 4. Drug of chioce for neonatal SE max. 30 mg/kg up to 600 mg Thiopental induction dose 4-8 mg/kg for SE It is not an effective long-term anticonvulsant. Principal use in SE is to facilitate ventilation and subsequent
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ALGORITHM MANAGEMENT OF SEIZURE
Diazepam IV: 0,3 – 0,5 mg/kg or Diazepam PR: BW <10 kg: 0,5 Repeat x 2 mg/kg every 5 BW >10 kg: 0,3 mg/kg, min or Midazolam? Diazepam PR: BW <10 kg: 5 mg BW >10 kg:10 mg

0-5 minutes A, B, C resuscitation Vital sign Hemodynamic monitor Brief history Neurologic exam. Bloodwork (lab.) 5-10 minutes

NO

Seizure stop ?

YES Stop medication

Diazepam IV : 0,3 – 0,5 mg/kg or Diazepam PR: BW <10 kg: 5 mg BW >10 kg: 10 mg (midazolam 0,05-0,1 mg/kg iv) Seizure stop ? Hypoglycemia: D25 2 ml/kg

YES Stop medication

NO

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Seizure stop ? 10-15 minutes
Prolonged Seizure Tend to SE

NO

Airway - Breathing – Circulation Sign of trauma/infection and Focal paresis Access intravenous line Examine: blood routine, glucose, electrolyte Phenytoin 15-20 mg/kg iv bolus 1 mg/kg/min

> 30 minutes

NO Status Epilepticus Seizure stop ?

Seizure stop ?

YES
12 hrs after initial Phenytoin 5-7 mg/kg iv

Phenobarbital 10-20 mg/kg IV (IM)

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Seizure stop ?
Refractor y Seizure

YES NO
12 hrs after initial dose Phenobarbital 3-4 mg/kg im + Phenytoin 5-7 mg/kg iv

Intubat e PICU
Midazolam 0,05-0,3 mg/kg iv, then maintenace 0,05-2 mcg/kg/min. or Thiopental 4-8 mg/kg iv or Propofol 1-2 mg/kg iv Respiratory depression → ventilator Muscle relaxant/paralyze CFAM - EEG

CFAM= cerebral function analysis monitoring
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HYPERTENSIO Percentile for age SBP OR DBP > 95th on three measurements N HYPERTENSIVE EMERGENCIES
SBP or DBP > 99th percentile for age with evidence of impaired end organ perfusion

A sudden severe increase in blood pressure to a level exceeding > 95th percentile for age

HYPERTENSIVE CRISIS

A set of symptoms including headache, convulsion and coma, associated with certain kidney diseases, pheochromocytoma, and drugs. 14

HYPERTENSIVE ENCEPHALOPAHTY

AGE

MODERATE HYPERTENSION (95TH-99TH %ILE) Systolic >110 Diastolic >75 Systolic >120 Diastolic >80 Systolic >125 Diastolic >82 Systolic >135 Diastolic >85

SEVERE HYPERTENSION (>99TH % ILE) Systolic >120 Diastolic >85 Systolic >130 Diastolic >85 Systolic >135 Diastolic >90 Systolic >145 Diastolic >90
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< 1 year 1-9 years 10-12 years 12-18 years

Severe vasoconstriction causing ischemia to end organs and excessive afterload for myocardium. CNS effects: a. Encephalopathy b. Intracranial hemorrhage Left ventricular failure with pulmonary edema Acute renal failure Retinopathy
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80-90% renal origin 1. Renal parenchymal or vascular disease 2. Vasculitis (e.g, SLE, polyarteritis nodosa) 3. Mineralocorticoid excess a. Corticosteroid use b. Adrenogenital syndromes c. Cushing’s syndrome 4. Catecholamine excess: a. Neuroblastoma b. Pheochromocytoma 5. Autonomic dysfunction
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The goal of acute parenteral therapy: 20% reduction in (MAP) MAP = (diastolic+1/3 [systolic-diastolic]) or Systolic - 2 diastolic : 3 (25% BP reduction within 1hrs) • • • Direct vasodilators or sympathetic inhibitors Relieve symptoms of end organ ischemia May need β adrenergic blockade to prevent reflex tachycardia
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Antihypertensive agent
DRUG Nifedipine Labetalol DOSE 0.25-0.5 mg/kg 0.1-0.25 mg/kg ROUTE SL IV COMMENTS
Predictable, can be drown up as liqiud from capsule for IV adm Slow IV push over 2 min, double every 10 min until effect is achieved (300mg total) then give last dose prn CI: in patients with asthma or who have received Ca++ channel blocker Intra-arterial monitoring reguired Repeat at 10-15 min intervals, causes hyperglycemia

Esmolol

500µg/kg/min x 2min then 50µg/kg/min Nitroprussid 0.5µg/kg/min Hydralazine 0.1-0.5 mg/kg Diazoxide 0.1-0.5 mg/kg

IV IV IV IV

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