373.4 📋 章末速蚘 Summary

373.4.1 🔑 䞀句話瞜結

Status epilepticus (SE) = ≥ 5 min seizure activity OR ≥ 2 seizures without recovery of consciousness (ILAE 2015 operational definition); categories — convulsive SE (CSE — GTC, may evolve to subtle CSE) vs non-convulsive SE (NCSE — altered consciousness on EEG, 8-37% of ICU comatose patients!) vs focal SE (with or without impaired awareness, epilepsia partialis continua); etiology — low ASM levels #1 in known epilepsy + withdrawal (alcohol, BZD) + CNS infection + stroke + TBI + metabolic (hyponatremia, hypoglycemia, hypocalcemia) + drug toxicity (cocaine, MDMA, theophylline, INH) + autoimmune encephalitis (NMDA-R) + hypoxic-ischemic + brain tumor; mortality — overall 10-20%, refractory 30-50%, super-refractory > 50%; higher in elderly + acute symptomatic etiology (anoxic > stroke > metabolic > infection) + duration > 1 hr; STAGED TREATMENT — Stage 1 (0-5 min) — stabilization: ABCs + position + IV access + glucose check + thiamine 100 mg IV (before glucose if possible) + dextrose if low + vital signs + labs (electrolytes, Ca, Mg, glucose, ASM levels, toxicology, ABG); Stage 2 (5-20 min) — first-line BENZODIAZEPINES: IV lorazepam 0.1 mg/kg (typical 4 mg) preferred + IV diazepam 0.15-0.2 mg/kg (10 mg) + IM midazolam 10 mg (RAMPART 2012 non-inferior when no IV) + buccal/intranasal midazolam + rectal diazepam — may repeat once; Stage 3 (20-40 min) — second-line ASM (ESETT 2019: three options comparable ~ 50% efficacy each): 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) — refractory SE anesthesia: intubate + ICU + continuous EEG monitoring + midazolam infusion (0.2 mg/kg load + 0.05-2 mg/kg/h) or propofol (1-2 mg/kg load + 30-200 ÎŒg/kg/min, PRIS risk) or pentobarbital (5-10 mg/kg load + 0.5-5 mg/kg/h) → goal seizure suppression or burst-suppression; continue 24-48 hr seizure-free then wean; Stage 5 (> 24 hr) — super-refractory SE: persistent despite anesthesia → multiple agents + ketogenic diet + ketamine NMDA antagonist + hypothermia + immunotherapy (IVIG/methylprednisolone/rituximab/cyclophosphamide/plasmapheresis) if autoimmune suspected + ECT + VNS + treat underlying; why treat early — BZDs less effective after 30-60 min (receptor trafficking — GABA-A internalized, NMDA externalized → excitotoxicity); NORSE (new-onset refractory SE in previously healthy) + FIRES (febrile infection-related epilepsy syndrome, often children) — often autoimmune anti-NMDA-R/anti-LGI1, immunotherapy + anakinra (IL-1 inhibitor) for FIRES; special causes — eclampsia (pregnancy + HTN + seizures → magnesium sulfate 4-6 g IV load + 1-2 g/h + delivery definitive), alcohol withdrawal (BZDs + thiamine before glucose), anti-NMDA-R encephalitis (young women + paraneoplastic ovarian teratoma → tumor removal + immunotherapy), INH toxicity (pyridoxine 1:1 with INH ingested, empiric 5 g IV), theophylline toxicity (BZDs/phenobarbital, charcoal hemoperfusion + HD, AVOID phenytoin), cefepime-induced encephalopathy NCSE (discontinue + dialysis), local anesthetic toxicity (lipid emulsion 20%)。

373.4.2 💊 治療粟芁

  • Stage 1 (0-5 min stabilization): ABCs + position on side + IV access + glucose stick → if low D50W 50 mL + thiamine 100 mg IV (before glucose if possible) + labs (electrolytes, Ca, Mg, glucose, ASM levels, toxicology, ABG)
  • Stage 2 (5-20 min first-line BZD): IV lorazepam 0.1 mg/kg (4 mg typical) preferred + IV diazepam 0.15-0.2 mg/kg (10 mg) + IM midazolam 10 mg (if no IV, RAMPART non-inferior) + buccal/intranasal midazolam + rectal diazepam; may repeat once if needed
  • Stage 3 (20-40 min second-line ASM) — ESETT 2019 three options comparable: IV levetiracetam 60 mg/kg over 10 min (max 4500 mg) + IV fosphenytoin 20 mg PE/kg over 10 min (cardiac monitoring) + IV valproate 40 mg/kg over 10 min (max 3000 mg); alternative IV phenobarbital + IV lacosamide
  • Stage 4 (> 40 min refractory): intubate + ICU + continuous EEG + arterial line + central line; choose: midazolam (0.2 mg/kg load + 0.05-2 mg/kg/h infusion) OR propofol (1-2 mg/kg load + 30-200 ÎŒg/kg/min, monitor for PRIS) OR pentobarbital (5-10 mg/kg load + 0.5-5 mg/kg/h); goal seizure suppression or burst-suppression on EEG; continue 24-48 hr seizure-free then wean slowly
  • Stage 5 (> 24 hr super-refractory): add another anesthetic or switch + ketogenic diet + ketamine (1-3 mg/kg load + 1-10 mg/kg/h NMDA antagonist) + hypothermia 32-34°C + immunotherapy (IVIG 2 g/kg + methylprednisolone pulse + rituximab + cyclophosphamide + plasmapheresis) if autoimmune + anakinra (IL-1 inhibitor) for FIRES + ECT + VNS + identify treat underlying
  • eclampsiamagnesium sulfate 4-6 g IV load + 1-2 g/h maintenance (not standard ASMs first) + delivery is definitive + antihypertensive
  • alcohol withdrawal SEbenzodiazepines + thiamine before glucose + treat underlying withdrawal (CIWA protocol)
  • anti-NMDA-R encephalitissearch for tumor (CT chest/abdomen/pelvis, transvaginal US ovaries — often teratoma) + tumor removal + IVIG/methylprednisolone/rituximab/cyclophosphamide
  • INH toxicitypyridoxine (vitamin B6) 1 g per gram INH ingested, or empiric 5 g IV if unknown + supportive
  • theophylline toxicityBZDs + phenobarbital (NOT phenytoin — ineffective for theophylline) + charcoal hemoperfusion + hemodialysis

373.4.3 🎯 盧醫垫的考前提醒

  1. SE definition (memorize): ≥ 5 min seizure activity OR ≥ 2 seizures without recovery of consciousness in between (ILAE 2015 operational); convulsive (CSE) vs non-convulsive (NCSE — 8-37% of ICU comatose patients, EASILY MISSED, cEEG essential) vs focal
  2. Why treat early: BZDs become less effective after 30-60 min (GABA-A receptors internalized + NMDA receptors externalized → excitotoxicity); time is brain
  3. Stage 2 first-line BZD doses (memorize): IV lorazepam 0.1 mg/kg (4 mg typical) preferred + IV diazepam 0.15-0.2 mg/kg (10 mg) + IM midazolam 10 mg (RAMPART 2012 non-inferior when no IV access); may repeat once
  4. Stage 3 second-line ASMs (ESETT 2019 three options comparable ~ 50% efficacy): IV levetiracetam 60 mg/kg + IV fosphenytoin 20 mg PE/kg + IV valproate 40 mg/kg — practitioner choice based on availability + comorbidities
  5. Refractory SE (Stage 4 > 40 min): intubate + ICU + continuous EEG monitoring + IV anesthetic infusion (midazolam OR propofol OR pentobarbital); goal seizure suppression or burst-suppression; continue 24-48 hr seizure-free then wean
  6. Super-refractory SE (> 24 hr) = persistent despite anesthesia → combination anesthetics + ketogenic diet + ketamine NMDA antagonist + hypothermia + immunotherapy if autoimmune (IVIG/methylprednisolone/rituximab/cyclophosphamide) + anakinra (IL-1 inhibitor) for FIRES + identify underlying
  7. Always do glucose + thiamine in Stage 1 — thiamine before glucose (Wernicke prevention); check ASM levels in known epilepsy
  8. Mortality: overall 10-20%; refractory SE 30-50%; super-refractory > 50%; higher with anoxic > stroke > metabolic > infection etiology + elderly + duration > 1 hr
  9. Special causes critical: eclampsia → magnesium sulfate (NOT standard ASMs first) + delivery; alcohol withdrawal → BZDs + thiamine; anti-NMDA-R encephalitis (young women, paraneoplastic ovarian teratoma) → tumor search + immunotherapy; INH toxicity → pyridoxine 1:1 or 5 g IV empiric; theophylline → BZDs + charcoal hemoperfusion + HD (AVOID phenytoin); cefepime-induced encephalopathy (NCSE in renal impairment → discontinue + dialysis)
  10. NORSE (new-onset refractory SE) + FIRES (febrile infection-related, often children) = often autoimmune even if antibody-negative → early empirical immunotherapy (IVIG + methylprednisolone + rituximab + cyclophosphamide) + anakinra for FIRES + ketogenic diet — do not wait for antibody results in refractory cases