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DISPONIBILI
?????????

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ARTICLES IN THE BOOK

  1. Acute abdomen
  2. Acute coronary syndrome
  3. Acute pancreatitis
  4. Acute renal failure
  5. Agonal respiration
  6. Air embolism
  7. Ambulance
  8. Amnesic shellfish poisoning
  9. Anaphylaxis
  10. Angioedema
  11. Aortic dissection
  12. Appendicitis
  13. Artificial respiration
  14. Asphyxia
  15. Asystole
  16. Autonomic dysreflexia
  17. Bacterial meningitis
  18. Barotrauma
  19. Blast injury
  20. Bleeding
  21. Bowel obstruction
  22. Burn
  23. Carbon monoxide poisoning
  24. Cardiac arrest
  25. Cardiac arrhythmia
  26. Cardiac tamponade
  27. Cardiogenic shock
  28. Cardiopulmonary arrest
  29. Cardiopulmonary resuscitation
  30. Catamenial pneumothorax
  31. Cerebral hemorrhage
  32. Chemical burn
  33. Choking
  34. Chronic pancreatitis
  35. Cincinnati Stroke Scale
  36. Clinical depression
  37. Cord prolapse
  38. Decompression sickness
  39. Dental emergency
  40. Diabetic coma
  41. Diabetic ketoacidosis
  42. Distributive shock
  43. Drowning
  44. Drug overdose
  45. Eclampsia
  46. Ectopic pregnancy
  47. Electric shock
  48. Emergency medical services
  49. Emergency medical technician
  50. Emergency medicine
  51. Emergency room
  52. Emergency telephone number
  53. Epiglottitis
  54. Epilepsia partialis continua
  55. Frostbite
  56. Gastrointestinal perforation
  57. Gynecologic hemorrhage
  58. Heat syncope
  59. HELLP syndrome
  60. Hereditary pancreatitis
  61. Hospital
  62. Hydrocephalus
  63. Hypercapnia
  64. Hyperemesis gravidarum
  65. Hyperkalemia
  66. Hypertensive emergency
  67. Hyperthermia
  68. Hypoglycemia
  69. Hypothermia
  70. Hypovolemia
  71. Internal bleeding
  72. Ketoacidosis
  73. Lactic acidosis
  74. Lethal dose
  75. List of medical emergencies
  76. Malaria
  77. Malignant hypertension
  78. Medical emergency
  79. Meningitis
  80. Neuroglycopenia
  81. Neuroleptic malignant syndrome
  82. Nonketotic hyperosmolar coma
  83. Obstetrical hemorrhage
  84. Outdoor Emergency Care
  85. Overwhelming post-splenectomy infection
  86. Paralytic shellfish poisoning
  87. Paramedic
  88. Paraphimosis
  89. Peritonitis
  90. Physical trauma
  91. Placenta accreta
  92. Pneumothorax
  93. Positional asphyxia
  94. Pre-eclampsia
  95. Priapism
  96. Psychotic depression
  97. Respiratory arrest
  98. Respiratory failure
  99. Retinal detachment
  100. Revised Trauma Score
  101. Sepsis
  102. Septic arthritis
  103. Septic shock
  104. Sexual assault
  105. Shock
  106. Simple triage and rapid treatment
  107. Soy allergy
  108. Spinal cord compression
  109. Status epilepticus
  110. Stroke
  111. Temporal arteritis
  112. Testicular torsion
  113. Toxic epidermal necrolysis
  114. Toxidrome
  115. Triage
  116. Triage tag
  117. Upper gastrointestinal bleeding
  118. Uterine rupture
  119. Ventricular fibrillation
  120. Walking wounded
  121. Watershed stroke
  122. Wilderness first aid
  123. Wound

 

 
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THE BOOK OF MEDICAL EMERGENCIES
This article is from:
http://en.wikipedia.org/wiki/Status_epilepticus

All text is available under the terms of the GNU Free Documentation License: http://en.wikipedia.org/wiki/Wikipedia:Text_of_the_GNU_Free_Documentation_License 

Status epilepticus

From Wikipedia, the free encyclopedia

 

Status epilepticus (SE) refers to a life threatening condition in which the brain is in a state of persistent seizure. Definitions vary, but traditionally it is defined as one continuous seizure or recurrent seizures without regaining consciousness between seizures for greater than 30 minutes. Many doctors, however, believe that 5 minutes is sufficient to damage neurons and that seizures are unlikely to self-terminate by that time.

In known epileptics, this condition is associated with poor compliance (adherence to medication regimen), alcohol withdrawal, and metabolic disturbances. As a primary presentation it normally indicates a tumour or abscess.

It can also be induced by nerve agents such as soman.[1]

Variants

Status epilepticus can be divided into two categories—convulsive and nonconvulsive, the latter of which is underdiagnosed.

Convulsive

Epilepsia partialis continua is a variant involving hour, day, or even week-long jerking. It is a consequence of vascular disease, tumours, or encephalitis, and is drug-resistant.

Generalized myoclonus is commonly seen in comatose patients following CPR and is seen by some as an indication of catastrophic damage to the neocortex.[2]

Treatments

Benzodiazepines

Shortly after it was introduced in 1963, diazepam became the first choice for SE. Even though other benzodiazepines such as clonazepam were useful, diazepam was relied upon almost exclusively. This began to change in 1975 with a preliminary study conducted by Waltregny and Dargent, who found that its pharmacological effects were longer lasting than those of an equal dose of diazepam.[3] This meant it did not have to be repeatedly injected like diazepam,[4] the effects of which would wear off 5-15 minutes later in spite of its 30-hour half-life. It has also been found that patients who were first tried on diazepam were much more likely to require endotracheal tubing than patients who were first tried on phenobarbital, phenytoin,[5] or lorazepam.[6]

Today, the benzodiazepine of choice is lorazepam for initial treatment due to its long (2-8 hour) duration of action and rapid onset of action. If that is not available, then diazepam should be given.[7] Sometimes, the failure of lorazepam alone is considered to be enough to classify a case of SE as refractory.

Phenytoin and fosphenytoin

Phenytoin was once another first-line therapy, although the prodrug fosphenytoin can be administered three times as fast and with far fewer injection site reactions. If these or any other hydantoin derivatives are used, then cardiac monitoring is a must if they are administered intravenously. Because the hydantoins take 15-30 minutes to work, a benzodiazepine or barbiturate is often co-administered. Because of diazepam's short duration of action, they were often administered together anyway.

Barbiturates

Before the benzodiazepines were invented, there were the barbiturates, which are still used today if benzodiazepines or the hydantoins are not an option. These are used to induce a barbituric coma. The barbiturate most commonly used for this is phenobarbital. Thiopental or pentobarbital may also be used for that purpose if the seizures have to be stopped immediately or if the patient has already been compromised by the underlying illness or toxic/metabolic-induced seizures; however, in those situations, thiopental is the agent of choice.

The failure of phenobarbital therapy does not preclude the success of a lengthy comatose state induced by a stronger barbiturate such as secobarbital. Such was the case for Ohori, Fujioka, and Ohta ca. 1998, when they induced a 10-month long coma (or "anesthesia" as they called it) in a 26-year-old woman suffering from refractory status epilepticus secondary to viral encephalitis and then tapered her off the secobarbital very slowly while using zonisamide at the same time.[8]

General anesthetics

If this proves ineffective or if barbiturates cannot be used for some reason, then a general anesthetic such as propofol[9] is tried; sometimes it is used second after the failure of lorazepam.[10] This also means putting the patient on artificial respiration. Propofol has been shown to be effective in suppressing the jerks seen in myoclonus status epilepticus, but as of 2002, there have been no cases of anyone going into myoclonus status epilepticus, undergoing propofol treatment, and then not dying anyway.[11]

Lidocaine

The use of lidocaine in status epilepticus was first reported in 1955 by Bernhard, Boem and Hojeberg.[12] Since then, it has been used in cases refractory to phenobarbital, diazepam, and phenytoin, and has been studied as an alternative to barbiturates and general anesthetics.[13][14] Lidocaine is a sodium channel blocker and has been used where sodium channel dysfunction was suspected.[15] However, in some studies, it was either ineffective or even harmful for most patients.[16] The last is not so surprising in light of the fact that lidocaine has been known to cause seizures in humans and laboratory animals at doses greater than 15 µg/mL[17] or 2-3 mg/kg.[18]

References and end notes

  1.   Wijdicks, Eelco F. M.; Parisi JE, Sharbrough FW (February 1994). "Prognostic value of myoclonus status in comatose survivors of cardiac arrest". Annals of Neurology 35 (2): 239-43. PMID 8109907.
  2.   McDonough, John H.; A. Benjamin, Joseph D. McMonagle, Thomas Rowland, Shih Tsung-Ming (February 2004). "Effects of fosphenytoin on nerve agent-induced status epilepticus". Drug and Chemical Toxicology 27 (1): 27-39. PubMed.
  3.   Waltregny, Alain; Jérôme Dargent (September/October 1975). "Preliminary study of parenteral lorazepam in status epilepticus". Acta Neurologica Belgica 75 (5): 219-29. PMID 3939.
  4.   Walker, JE; RW Homan, MR Vasko, IL Crawford, RD Bell, WG Tasker (September 1979). "Lorazepam in status epilepticus". Annals of Neurology 6 (3): 207-13. PMID 43112.
  5.   Orr, Richard A.; Robert J. Dimand, Shekhar T. Venkataraman, Valerie A. Karr, Kathleen J. Kennedy (September 1991). "Diazepam and intubation in emergency treatment of seizures in children". Annals of Emergency Medicine 20 (9): 1009-13. DOI:10.1016/S0196-0644(05)82981-6. PubMed.
  6.   Appleton, Richard; A. Sweeney, Imti Choonara, Joan Robson, Elizabeth Molyneux. (August 1995). "Lorazepam versus diazepam in the acute treatment of epileptic seizures and status epilepticus". Developmental Medicine and Child Neurology 37 (8): 682-8. PubMed.
  7.   Pang, Trudy; Lawrence J. Hirsch (July 2005). "Treatment of Convulsive and Nonconvulsive Status Epilepticus". Current Treatment Options in Neurology 7 (4): 247-259. PubMed.
  8.   Ohori, Nobuhira; Fujioka Y, Ohta M. (May 1998). "[Experience in managing refractory status epilepticus caused by viral encephalitis under long-term anesthesia with barbiturate: a case report]". Rinsho Shinkeigaku 38 (5): 474-7. PMID 9806000. (Japanese)
  9.   Pourrat, X; JM Serekian, D Antier, J. Grassin (June 9, 2001). "[Generalized tonic-clonic status epilepticus: therapeutic strategy]". Presse Médicale 30: 1031-6. PubMed. (French).
  10.   Marik, Paul E.; Joseph Varon (2004). "The management of status epilepticus". Chest 126 (2): 582-91. PMID 15302747.
  11.   Wijdicks, Eelco F.M. (July 2002). "Propofol in myoclonus status epilepticus in comatose patients following cardiac resuscitation". Journal of Neurology Neurosurgery and Psychiatry 73 (1): 94-5. PMID 12082068.
  12.   Bernhard, CG; Bohm E, Hojeberg S (August 1955). "A new treatment of status epilepticus; intravenous injections of a local anesthetic (lidocaine)". AMA Archives of Neurology and Psychiatry 74 (2). PMID 14397899.
  13.   Aggarwal, Praveen; Jyoti Prakash Wali (May 1993). "Lidocaine in refractory status epilepticus: a forgotten drug in the emergency department". American Journal of Emergency Medicine 11 (3): 243-4. DOI:10.1016/0735-6757(93)90135-X. PubMed.
  14.   Sugiyama, N; Hamano S, Mochizuki M, Tanaka M, Eto Y (November 2004). "[Efficacy of lidocaine on seizures by intravenous and intravenous-drip infusion]". No To Hattatsu 36 (6): 451-4. PMID 15560386. (Japanese)
  15.   Sawaishi Yukio; Yano Tamami, Enoki Masamichi, and Takada Goro (February 2002). "Lidocaine-dependent early infantile status epilepticus with highly suppressed EEG". Epilepsia 43 (2): 201-4. DOI:10.1046/j.1528-1157.2002.25301.x. PubMed.
  16.   Tanabe Takuya; Suzuki Shuuhei, Shimakawa Shuichi, Yamashiro Kuniteru, Tamai Hiroshi (January 1999). "Problems of intravenous lidocaine treatment in status epilepticus or clustering seizures in childhood". No To Hattatsu 31 (1): 14-20. PMID 10025129. (Japanese)
  17.   DeToledo, John C. (June 2000). "Lidocaine and Seizures". Therapeutic Drug Monitoring 22 (3): 320-322. PMID 10850400.
  18.   Steven C. Schachter. Lidocaine. epilepsy.com/professionals. Adapted from: Najjar S, Devinsky O, Rosenberg AD, et al (2002). “Procedures in epilepsy patients”, ed. Ettinger AB and Devinsky O: Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann, 499–513.
Retrieved from "http://en.wikipedia.org/wiki/Status_epilepticus"