373.3 🏥 內科專科考前版

373.3.1 Mechanistic Deep Dive

373.3.1.1 Pathophysiology of SE

  • Initial: imbalance of excitation/inhibition
  • Sustained: receptor trafficking changes
    • GABA-A receptors internalized (BZD-resistant)
    • NMDA receptors externalized (excitotoxicity)
  • Excitotoxic neuronal injury (calcium-mediated)
  • Apoptosis + necrosis
  • Long-term: neuronal loss, gliosis, epileptogenesis

373.3.1.2 Why Treat Early

  • BZDs less effective after 30-60 min (receptor changes)
  • Refractoriness develops with time
  • Permanent injury occurs

373.3.2 Recent Trials & Updates

373.3.2.1 ESETT (2019)

  • Established Status Epilepticus Treatment Trial
  • 3-arm RCT: fosphenytoin vs valproate vs levetiracetam
  • All ~ 50% effective
  • Practitioner choice based on availability + comorbidities

373.3.2.2 RAMPART (2012)

  • IM midazolam vs IV lorazepam in pre-hospital
  • IM midazolam non-inferior
  • Useful when IV access difficult

373.3.2.3 KETASER01 (2023)

  • Ketamine vs midazolam in refractory SE
  • Ketamine non-inferior

373.3.2.4 Brivaracetam IV

  • Faster onset than levetiracetam
  • May replace in protocols
  • FDA-approved adjunct

373.3.2.5 Lacosamide for SE

  • Added in some protocols
  • Available IV
  • PR prolongation caveat

373.3.3 High-Yield Specialist Points

373.3.3.1 Subtle CSE

  • After prolonged convulsive activity
  • Minor motor activity (eyelid, facial twitches)
  • Coma
  • Continuous electrical activity
  • Easy to miss
  • Treat aggressively

373.3.3.2 NORSE (New-Onset Refractory SE)

  • Previously healthy patients
  • Refractory SE
  • No identified cause initially
  • Often autoimmune (anti-NMDA-R, anti-LGI1, others)
  • Immunotherapy crucial
  • Often need multiple agents
  • Ketogenic, anakinra (IL-1 inhibitor for FIRES)

373.3.3.4 Pyridoxine for INH Toxicity

  • Pyridoxine 1:1 with INH ingested
  • Empiric 5 g IV if dose unknown
  • Treats both seizures and acidosis

373.3.3.5 Theophylline Toxicity

  • Refractory seizures
  • Treatment: BZDs, phenobarbital (not phenytoin)
  • Charcoal hemoperfusion + HD
  • Severe = level > 100 ÎŒg/mL

373.3.3.6 Bupropion Overdose

  • Seizures common
  • Treatment: BZDs, supportive

373.3.3.7 Cefepime-Induced Encephalopathy

  • NCSE
  • Renal impairment common
  • Discontinue cefepime + dialysis

373.3.3.8 Local Anesthetic Toxicity

  • Bupivacaine cardiotoxic + seizures
  • Lipid emulsion 20% rescue

373.3.3.9 Pseudo-Status (PNES)

  • Psychogenic
  • May mimic SE
  • Video-EEG diagnostic
  • Avoid intubation/anesthesia if just PNES
  • But unclear — treat as SE while obtaining EEG

373.3.3.10 Convulsive Syncope

  • Brief jerks during syncope
  • Different from SE
  • Cardiac workup

373.3.4 Pearls

  • SE = ≥ 5 min or ≥ 2 without recovery
  • Staged treatment (BZD → ESETT ASM → anesthesia → super-refractory)
  • BZDs more effective early (receptor trafficking)
  • ESETT 2019: levetiracetam, fosphenytoin, valproate all comparable second-line
  • Anesthesia for refractory: midazolam, propofol, pentobarbital
  • cEEG essential after anesthesia + for NCSE
  • NCSE common in ICU comatose (8-37%)
  • Mortality 10-20% overall; refractory 30-50%; super-refractory > 50%
  • NORSE/FIRES: often autoimmune, immunotherapy + anakinra
  • Eclampsia: magnesium sulfate + delivery
  • Anti-NMDA-R: immunotherapy + tumor search