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EXCITATION INCREASE
Na+ channel antagonists Ca2+ channel antagonists Glutamate receptor antagonists GABAA agonists Enhanced GABA levels K+ channels modulators
Feb 4, 2005
Epidemiology - SE
life threatening USA: -102,000 -152,000 cases / year - 52,000 deaths / year of new cases of epilepsy, 12 -30% present in Status generalized Status is most common form - and subject of this review
Pathophysiology - SE
numerous mechanisms - poorly understood
excess excitation or ineffective inhibition there are excitatory and inhibitory receptors in the brain - activity is usually in balance
Pathophysiology - SE cont d
GLUTAMATE = the major excitatory AA neurotransmitter in brain
any factor which increases Glutamate activity can lead to seizures e.g. 1987- contaminated with Domoic acid, a 1987glutamate analog --> profound SE / deaths -->
Pathophysiology - SE
GABA = main inhibitory neurotransmitter
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GABA antagonists can cause SE eg Penicillins, other antibiotics prolonged sz can desensitize GABA receptors
Pathophysiology - SE
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KLASIFIKASI:
1. STATUS EPILEPTIKUS KONVULSIF ( BANGKITAN UMUM TONIK-KLONIK). TONIK2. STATUS EPILEPTIKUS NON KONVULSIF ( BANGKITAN LENA,PARSIAL KOMPLEKS)
Status epilepticus
It is a medical emergency requires prompt and aggressive treatment Therapy should be aimed at:
Rapid termination of status epilepticus Prevention of seizure recurrence Treatment of underlying cause
Management of SE
ABC s (+ monitor / O2 / large IV s) START PHARMACOTHERAPY Metabolic acidosis common - if severe, severe, give Bicarb if intubating / ventilating - avoid longlongacting n-m blockers - sz activity nbeware hyperthermia 2 sz - in 30-80% 30--> passive cooling -->
Management of SE
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Management of SE
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Management of SE
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Status Epilepticus-Definitive Treatment EpilepticusDiazepam - 10mg IV push over 30-60 seconds 30repeat after 10-15mins upto 30mg 10(5mg/min). Repeat after 2-4hrs. 100mg/day 2i.Good results, easy to administer. (fast acting, short lasting) ii. If two doses fail to stop status, then further doses probably won't work either. iii. Side effects -- hypotension, iii. bradycardia, bradycardia, respiratory depression, cardiac arrest, depresses mental status.
0-60/90 mnt: Bila terus kejang Phenitoin 15-18 mg/kg pelan 15(kecepatan 50 mg/mnt.) 90 mnt masih kejang rawat dengan pemberian anestesi.
SE NON KOVULSIKUS:
1/3 DARI KASUS. PILIHAN OBAT : SE LENA : BENZODIAZEPINE IV VALPROAT IV. PARSIAL KOMP : CLOBAZAM LORAZEPAM/IV PHENYTOIN/IV. PADA PASIEN KOMA: PHENYTOIN/IV ANESTESI.
EPILEPSI REFRAKTER/INTRACTABLE EPILEPSY. BANGKITAN YANG TIDAK BISA DATASI WALAU DENGAN OAE YANG MAKSIMAL. ETILOGI : BIASANYA OLEH KARENA ADANYA SKLEROSIS PADA HIPOKAMPUS.
Coma
Consciousness requires arousal (coming from the brainstem reticular formation) and content (the cerebral hemispheres) Alterations in consciousness stem from: Disorders affecting the reticular formation Disorders affecting both cerebral hemispheres Disorders affecting the connections between the brainstem and the hemispheres
Conscious level--severe
Verbal Response
5 - oriented 4 - confused conversation 3 - inappropriate words 2 - incomprehensible sounds 1 - none
EXAMINE Coma
Four domains to examine: examine: Pupillary responses Extraocular movements Respiratory pattern Motor responses
Initial Treatment
Airway Breathing Circulation ABC - identify and address life threatening inadequacies Treat rapidly progressive metabolic disorders -- hypoglycemia Evaluate for intracranial hypertension and imminent herniation and treat
Airway
Intubate (protecting neck) anyone who will let you
Any of the following are adequate criteria
GCS < 9 Airway not secure or open Respiration not adequate Any significant respiratory failure Uncertainty regarding direction or rate of mental status changes, particularly if constant observation not available (during CT scans, etc..)
Breathing
Evaluate - is patient moving adequate air, is respiratory rate appropriate, is gas exchange adequate, are breath sounds adequate and symmetrical Must assure oxygenation and ventilation If intubated don t forget to ventilate Identify and immediately treat problems - pneumothorax, airway pneumothorax, obstruction, etc..
Circulation
Is patient in shock?
Check pulses, heart rate, blood pressure, perfusion Remember hypotension is late sign of shock
Circulation
Use isotonic solutions and blood, as indicated. Do not use hypotonic solutions to treat shock, particularly patients with coma or possible cerebral edema Identify life threatening hemorrhage and control it.