373.2 𩺠åèç
373.2.1 é«é »èé»
373.2.1.1 Definitions
- ⥠5 min seizure, OR ⥠2 without recovery
- Time 1 (treat by): 5 min CSE; 10 min focal impaired
- Time 2 (injury by): 30 min CSE; 60 min focal
373.2.1.3 Etiology
- Low ASM levels (#1 in epilepsy patients)
- Withdrawal
- CNS infection
- Stroke
- TBI
- Metabolic
- Drug toxicity
- Autoimmune encephalitis
373.2.1.4 Staged Treatment
Stage 1 (0-5 min): - ABCs + glucose + thiamine + IV
Stage 2 (5-20 min) â First-Line BZD: - IV lorazepam 4 mg (0.1 mg/kg) - IV diazepam 10 mg - IM midazolam 10 mg - Buccal/intranasal midazolam
Stage 3 (20-40 min) â Second-Line ASM (ESETT 2019: comparable): - IV levetiracetam 60 mg/kg (max 4500 mg) - IV fosphenytoin 20 mg PE/kg - IV valproate 40 mg/kg (max 3000 mg)
Stage 4 (> 40 min) â Refractory: - ICU + intubate + cEEG - Midazolam infusion - Propofol infusion - Pentobarbital
Stage 5 (> 24 hr) â Super-Refractory: - Multiple agents - Ketogenic - Ketamine - Immunotherapy
373.2.1.5 ESETT (2019)
- Fosphenytoin vs valproate vs levetiracetam in second-line
- All ~ 50% effective; comparable
- Practitioner choice
373.2.1.9 Special Causes
Eclampsia: - Pregnancy + HTN + seizures - Magnesium sulfate (not standard ASMs first) - Delivery
Alcohol Withdrawal: - Benzodiazepines for SE - Thiamine before glucose - Treat underlying withdrawal
Anti-NMDA-R Encephalitis: - Young women - Paraneoplastic (ovarian teratoma) - Immunotherapy + tumor search
Theophylline Toxicity: - Refractory SE - Treatment: charcoal, hemodialysis, BZDs (avoid phenytoin â ineffective)
INH Toxicity: - Pyridoxine deficiency - Pyridoxine IV (gram-for-gram with INH ingested, or empiric 5 g)