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CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK

For the chapter in the Wells Handbook, please go to Chapter 57. Status Epilepticus.

KEY CONCEPTS

KEY CONCEPTS

  • Image not available. Status epilepticus (SE) is a neurologic emergency that may be associated with significant morbidity and mortality.

  • Image not available. Generalized convulsive status epilepticus (GCSE) is defined as any recurrent or continuous seizure activity lasting longer than 30 minutes in which the patient does not regain baseline mental status. Any seizure that does not stop within 5 minutes should be aggressively treated as impending SE.

  • Image not available. There are two types of SE, GCSE and nonconvulsive status epilepticus (NCSE). GCSE is the most common type and can be divided into four stages: (1) impending, (2) established, (3) refractory, and (4) super-refractory.

  • Image not available. Although the pathophysiology of GCSE is unknown, experimental models have shown that there is a dramatic decrease in γ-aminobutyric acid–mediated inhibitory synaptic transmission and that glutamatergic excitatory synaptic transmission sustains the seizures.

  • Image not available. During prolonged GCSE, GABAA receptors move from the synaptic membrane into the cytoplasm where they become functionally inactive. A loss of these receptors on the synaptic surface may result in time-dependent pharmacoresistance to benzodiazepines.

  • Image not available. The main purpose of treatment is to prevent or decrease morbidity and mortality of prolonged seizures. Pharmacologic treatment needs to be rapid and aimed at terminating both electrical and clinical seizures. The probability of poorer outcomes increases with increased length of electrographic seizure activity.

  • Image not available. Lorazepam is the preferred benzodiazepine in treatment of GCSE because of its efficacy and long duration of action in the central nervous system (CNS). Midazolam is the preferred benzodiazepine for intramuscular (IM) and intranasal (IN) administration.

  • Image not available. Although practice is slowly moving to other anticonvulsants, the hydantoins (phenytoin and fosphenytoin) continue to be the long-acting anticonvulsants used most frequently. Either phenytoin or fosphenytoin should be given concurrently with benzodiazepines.

  • Image not available. If GCSE is not controlled by two anticonvulsants, the GCSE is considered to be refractory. In these cases, anesthetic doses of midazolam, pentobarbital, ketamine, or propofol may be used.

Image not available. Status epilepticus (SE) is a common neurologic emergency that is associated with brain damage and death. The Commission on Classification and Terminology and the Commission on Epidemiology of the International League Against Epilepsy (ILAE) have recently proposed a new definition: Conceptually, SE results from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms, which lead to abnormally, prolonged seizures. There are two operational dimensions to this new definition. First, the length of the seizure and the time point (5 minutes) beyond which the seizure should be regarded as “continuous seizure activity.” Second, is the time of ongoing seizure activity after which there is a risk of long-term consequences (30 minutes). Both time points are based on animal experiments and clinical research; hence, these time points should be considered the best estimates currently available.1 Image not available. The traditional definition defines SE as (a) any seizure lasting longer than 30 minutes ...

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