Fifth Stage
Internal Medicine
Dr. Abbas / Lec . 11
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Status epilepticus
Is seizure activity not resolving spontaneously or recurrent seizures with no
recovery of consciousness in between
Status has a mortality of 10-15%. Over 50% of cases occur without a previous
history of epilepsy. However, about 25% with apparent refractory status have
pseudostatus(non-epileptic attack disorder). The iatrogenic morbidity here is
significant
Complications
1-Aspiration [airways obstruction]
2-Hypotension
3-Cardiac arrhythmia
4-Renal or hepatic failure
Causes
1-Drug with drawl
2-C.NS infection
3-Neoplasm
4-Metabolic [hypoglycemia, hyponatremia ,hypocalcaemia]
Management
1-Cear the airways and give oxygen to prevent cerebral hypoxia
2-Check the vital signs
3-send the blood for investigations
4-if seizure continue for more than 5 min; Give diazepam 10 mg IV or rectal or
lorazepam 4 mg IV
5-correct any metabolic tiger [hypoglycemia]
6-if seizure continue after 30 min; IV infusion with one of the followings
Phenytoin 15mg\kg at 50mg\min
Fosphyntoin 15mg\kg at 100 mg\min
Phenobarbital 10 mg\kg at 100 mg\ min
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Cardiac monitoring and pulse oximetry, blood gases and blood pressure and
respiration
7-if seizure still after 60 min; transfer to intensive care , start treatment for refractory
status with intubation, ventilation and general anesthesia using propofol or thiopental
and EEG monitoring
8-once status controlled; commence longer-term anticonvulsant medication with one
of; sodium valproate 10mg\kg IV then800-2000mg\day
Phenytoin or carbazepam 400 mg by NG tube then 400-1200 mg\ day
Investigate the cause
Treatment of epilepsy
Therapy for a patient with a seizure disorder is almost always multimodal and
includes
1- treatment of underlying conditions that cause or contribute to the seizures,
2- avoidance of precipitating factors,
3- suppression of recurrent seizures by prophylactic therapy with antiepileptic
medications or surgery, and
4- addressing a variety of psychological and social issues.
Guideline for choice of AEDs
1-focal onest or secondary generalized
first line –lamotrigine
Second line -carbamazepam
2-generalised TC seizure
first line-sodium valproate ,levertiracetam
Second line –lamotrigine,topiramate
3-absence
first line – ethosuximide
Second line-sodium valproate
4-myoclonic
first line-sodium valproate
Second line –levetiracetam ,clonazepam
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Side effect of AEDs
Phenytoin
Dizziness
Diplopia
Ataxia
Incoordination
Confusion
Gum hyperplasia
Lymphadenopathy
Hirsutism
Osteomalacia
Facial coarsening
Skin rash
Level increased by isoniazid, sulfonamides, fluoxetine
Level decreased by enzyme-inducing drugs
Altered folate metabolism
Carbamazepine
Ataxia
Dizziness
Diplopia
Vertigo
Aplastic anemia
Leukopenia
Gastrointestinal irritation
Hepatotoxicity
Hyponatremia
Level decreased by enzyme-inducing drugs
Level increased by erythromycin, propoxyphene, isoniazid, cimetidine, fluoxetine
Valproic acid
Ataxia
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Sedation
Tremor
Hepatotoxicity
Thrombocytopenia
Gastrointestinal irritation
Weight gain
Transient alopecia
Hyperammonemia
Level decreased by enzyme-inducing drugs
Lamotrigine
-Dizziness
Diplopia
Sedation
Ataxia
Headache
Skin rash Stevens-Johnson syndrome
Level decreased by enzyme-inducing drugs and oral contraceptives
Ethosuximide
Lethargy
Headache
Gastrointestinal irritation
Skin rash
Bone marrow suppression
Topiramate
Established
not
Psychomotor
Slowing
Sedation
Speech or language problems
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Fatigue
Paresthesias
Renal stones (avoid use with other carbonic anhydrase inhibitors)Glaucoma
Weight loss
Hypohydrosis
Level decreased by enzyme-inducing drugsa
Pregnancy and epilepsy
The overall incidence of fetal abnormalities in children born to mothers with
epilepsy is 5–6%, compared to 2–3% in healthy women. Part of the higher
incidence is due to teratogenic effects of antiepileptic drugs, and the risk
increases with the number of medications used (e.g., 10% risk of malformations
with three drugs).
Since the potential harm of uncontrolled seizures on the mother and fetus is
considered greater than the teratogenic effects of antiepileptic drugs, it is
currently recommended that pregnant women be maintained on effective drug
therapy. When possible, it seems prudent to have the patient on monotherapy at
the lowest effective dose, especially during the first trimester. Patients should also
take folate (1–4 mg/d), since the antifolate effects of anticonvulsants are thought
to play a role in the development of neural tube defects, although the benefits of
this treatment remain unproved in this setting.
Enzyme-inducing drugs such as phenytoin, phenobarbital, and primidone cause a
transient and reversible deficiency of vitamin K–dependent clotting factors in
~50% of newborn infants. Although neonatal hemorrhage is uncommon, the
mother should be treated with oral vitamin K (20 mg/d) in the last 2 weeks of
pregnancy, and the infant should receive vitamin K (1 mg) at birth.
Contraception
Special care should be taken when prescribing antiepileptic medications for
women who are taking oral contraceptive agents. Drugs such as carbamazepine,
phenytoin, phenobarbital, and topiramate can significantly antagonize the effects
of oral contraceptives via enzyme induction and other mechanisms. Patients
should be advised to consider alternative forms of contraception, or their
contraceptive medications should be modified to offset the effects of the
antiepileptic medications.
Breast-Feeding
Antiepileptic medications are excreted into breast milk to a variable degree..
Given the overall benefits of breast-feeding and the lack of evidence for long-term
harm to the infant by being exposed to antiepileptic drugs, mothers with epilepsy
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can be encouraged to breast-feed. This should be reconsidered, however, if there
is any evidence of drug effects on the infant, such as lethargy or poor feeding
Prognosis
Overall, generalised seizures are more readily controlled than partial seizures.
The presence of a structural lesion makes complete control of the epilepsy less
likely.
EPILEPSY: OUTCOME AFTER 20 YEARS
50%: seizure-free, without drugs, for last 5 years
20%: seizure-free for last 5 years but continue to take medication
30%: seizures continue in spite of anti-epileptic therapy
Thank you,,,