What are the drugs that quickly end seizures? How do you choose? Are you confused by the myriad of antiepileptic and related medications? The Pyramid of Medication for Persistent Status Epilepticus (specifically for adults with spasticity persistent status epilepticus) helps you get it done!
1. What do the Pyramid of Medication for Status Epilepticus SE, RSE and Super-RSE mean?
In 2001, the International League Against Epilepsy (ILAE) Classification and Terminology Committee revised the definition of status epilepticus (SE) to include seizures that exceed the duration of seizures in most patients of that type, or recurrent seizures in which central nervous system function does not return to normal baseline during the interictal period. As clinical trials and basic research continued, the limit of SE seizure duration was gradually shortened from the earliest 30 min to an operational definition suitable for clinical application, i.e., each convulsive seizure lasting more than 5 min, or more than 2 seizures with incomplete recovery of consciousness between seizures; SE is a common neurological emergency with high morbidity and disability, and the treatment goal is to rapidly terminate clinical seizures and The goal of treatment is to rapidly terminate clinical seizures and EEG epileptiform discharges. If not properly controlled, SE can develop into refractory status epilepticus (RSE), which is called RSE when adequate doses of first-line anti-SE drugs, such as benzodiazepines followed by another antiepileptic drug, fail to terminate convulsive seizures and EEG pathological discharges; RSE can also develop into super-refractory status epilepticus (SRE). RSE can also develop into super-refractory status epilepticus (super-RSE), which is defined as super-RSE when the clinical convulsive seizures or EEG epileptic discharges cannot be terminated or recurred after more than 24 h of SE treatment with anesthetic drugs (including the process of anesthetic maintenance or dose reduction).
RSE and super-RSE significantly increase the rates of death and disability.
The bottom of the pyramid is SE medication
1. lorazepam 0.1 mg/kg (1 to 2 mg/min) intravenously is preferred (in fact, there is no intravenous form of lorazepam in China, and although it is recommended by the guidelines, it is difficult to administer clinically).
2. if lorazepam is not available, diazepam 10 mg (2-5 mg/min) followed by phenytoin sodium 18 mg/kg (<50 mg/min) intravenously (not much used clinically because of the cardiac side effects of phenytoin sodium).
3. If phenytoin sodium is not available, the following options are available.
(1) diazepam 10 mg (2-5 mg/min) intravenous follow-up 4 mg/h intravenous pumping
(2) Valproic acid 15-45 mg/kg (<6 mg/kg?min) followed by 1-2 mg/kg?h intravenous pumping.
(3) phenobarbital 15-20 mg/kg (50-100 mg/min) intravenously.
(4) Levetiracetam 1000-3000 mg intravenously (the intravenous form of levetiracetam is not seen in China, although the drug has risen to first-line status and its use is rare in clinical practice).
4, clonazepam 1-4 mg 30 seconds or so slowly intravenous, if the persistent state is not controlled, the original dose can be repeated 1-2 times every 20 minutes, the maximum amount of adults do not exceed 20 mg per day; (no foreign clonazepam intravenous form, so the major guidelines are not recommended clonazepam intravenous form as the first choice of drugs for SE. Clonazepam and diazepam belong to the same benzodiazepine class of drugs, and there are no major differences in efficacy between them, and they are easily available in large and small hospitals. However, diazepam is often prone to precipitates when combined with saline and needs to be combined with 5% glucose solution; while intravenous infusion of glucose in patients with persistent epilepsy is likely to aggravate lactic acidosis and cerebral edema. (Clonazepam does not have the problem of compatibility with saline, and is widely used in clinical practice.)
5. Fosphenytoin is a new type of antiepileptic drug and is not routinely recommended for the time being.
6. it is worth mentioning that midazolam 10 mg intramuscularly in the second level of the pyramid can be given when intravenous access cannot be established.
7. immediate transition to intramuscular or oral medication of the same or similar type, such as phenobarbital, valproic acid, levetiracetam, clonazepam, after termination of SE.
The second level of the pyramid is often the RSE medication
1. midazolam (0,2 mg/kg intravenously, followed by continuous intravenous pumping of 0,05-0,40 mg/kg. h) is recommended
2. or propofol (2-3 mg/kg intravenously, with the possibility of additional 1-2 mg/kg until seizure control, followed by continuous intravenous pumping of 4-10 mg/kg. h).
3. thiopental sodium and pentobarbital are not routinely recommended for the time being because of adverse drug reactions, less clinical experience with the drug, and difficulty in obtaining it.
4. oral antiepileptic drugs, such as levetiracetam, carbamazepine (or oxcarbazepine), valproic acid, etc., should be administered immediately after RSE termination.
The third level of the pyramid is Super-RSE medication
In addition to the representative drug ketamine anesthesia, a combination of multiple therapies is required for control, such as inhaled narcotic anesthesia, mild hypothermia, immunomodulation, surgery, and ketogenic diet, and close monitoring in the neurocritical care unit throughout.
If you have the structure of the pyramids, but still feel that the pyramids are like a maze, winding around, can not be left and right, like a fish to swim in it, then take a look at the “Pyramid Tour Roadmap” to help you grasp the general direction, delete the complexity and simplify, clear the sequence, do not miss the important “attractions”.
2. Bearing in mind the “pyramid structure” and the “pyramid tour roadmap”, I believe that the order of medication selection for persistent epilepsy can help you remember the selection of medication for persistent epilepsy.
However, the pyramid of medications for persistent epilepsy is not unchanging. In recent years, some new antiepileptic drugs have been added and some old drugs have been gradually abandoned.