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Characteristics of Agents for Status Epilepticus
First line therapy( emergency )
-Hyponatremia.
-Hypernatremia.
-Status epilepticus.
-CNS infection.
-Intracranial pressure treatment.
-Paroxysmal sympathetic hyperactivity.
-Acute ischemic stroke.
-Intracerebral hemorrhage.
-Subarachnoid hemorrahage.
-Interventional endovascular treatment.
-Acute spinal cord injury.
-Brain tumor.
-Citical illness polyneuropathy.
-Guillian-Biarre syndrome.
-Myasthenia crisis.
-Serotonin syndrome.
-Benzodiazepine therapy preferred
1- lorazepam 0.1 mg/kg IV (max : 4mg/dose).
2- Midazolam 5–10 mg IM (preferred for patients with no intravenous access).
3- Diazepam IV (0.15–0.2 mg/kg, max :10 mg/dose).
or rectally (0.2–0.5 mg/kg,max :20 mg/dose).
Not recommended as first line for hospitalized patient due to short duration of seizure.
ACUTE ISCHEMIC STROKE
Second-line therapy (urgent)
*Initiate an anticonvulsant after benzodiazepine therapy if seizures persist
or if a maintenance therapy needs to be initiated to prevent future seizures.
* Can add anticonvulsants if the patient does not respond to treatment and is not intubated
1- Valproate 20–40 mg/kg IV.
2- (Fos)phenytoin 18–20 mg/kg IV.
3- Phenobarbital 20 mg/kg IV.
4- Levetiracetam 1-3 g IV.
Diagnosis
Serum [Na+] 130–135 mEq/L
Serum [Na+] < 120 mEq/L
• Headache
• Restlessness
• Lethargy
• Seizures
• Brain stem herniation
• Respiratory arrest
• Death
• Asymptomatic
• Headache
• Nausea
• Vomiting
• Fatigue
• Confusion
• Anorexia
• Muscle cramps
•Depressed reflexes
• Malaise
• Unsteadiness
• Headache
• Nausea
• Vomiting
• Fatigue
• Confusion
• Anorexia
• Muscle cramps
Fifth leading cause of death.
1. Diagnostic tests
a. Neurologic examination.
b. Vital signs.
c. NIH Stroke Scale{national institute health}
(greater than 25 is severe, range 1–42).
d. CT scan or magnetic resonance imaging (MRI) of the brain.
e.Chest radiography ( if lung disease).
f.EEG (if seizure).
2. blood tests:
a. Blood glucose
b. INR, activated partial prothrombin time (consider thrombin time, anti–factor Xa [anti-Xa] activity for newer oral anticoagulants)
c. Complete blood cell count (CBC)
d. Tests for hypercoagulable state
Third-line therapy (refractory)
Differential Diagnosis for SIADH and CSWS
-Deffinition: seizures persist after first and second –line therapy, RSE should be treated aggressively with continuous infusion anesthetic agents.
-The patient should be intubated before starting therapy.
- RSE agents should be titrated to burst suppression (the almost total elimination of electrical activity on EEG, except for short “bursts” of cortical activity [typically therapy is titrated to 2–5 bursts/minute]) or termination of electrographic seizure activity, depending on provider preference.
-Treat RSE for 24–48 hours before trying to taper these continuous agents.
Serum sodium
(mEq/L)
Serum Osmolality
(mOsm/L)
Urine Osmolality
(mOsm/L)
Urine Sodium
(mEq/L)
Intravascular
Volume Status
> 200
Euvolemia
SIADH
> 25
<135
< 285
CSWS
> 200
< 285
> 25
<135
Hypovolemia
Differentiating Between Syndrome of Inappropriate Antidiuretic Hormone (SIADH) and Cerebral Salt-Wasting Syndrome (CSWS)
1. Typically made by assessing intravascular volume. Patients with SIADH tend to be euvolemic or hypervolemic with hyponatremia because of excessive antidiuretic hormone (ADH) release, whereas
patients with CSWS tend to be hypovolemic with hyponatremia because of inappropriate urinary excretion of Na & extracellular fluid.
2. Measure intravascular volume using a central venous pressure catheter or similar invasive monitoring.
3. Noninvasive hemodynamic monitoring devices.
4. Monitor fluid balance, weight & skin turgor.
5. Echocardiogram to estimate ventricular filling pressures.
Causes:
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Euvolemic or hypervolemic due to ADH release.
Cerebral Salt Wasting Syndrome (CSWS)
Hypovolemic due to inappropriate urinary excretion & extracellular fluid.
**Continuous infusion anesthetics for RSE
i. Midazolam high-dose infusion 0.05–2 mg/kg/hour (target burst suppression).
ii. Pentobarbital infusion (loading dose about 25 mg/kg total, continuous infusion 0.5–5 mg/kg/hour [target burst suppression]).
iii. Propofol infusion 20–200 mcg/kg/minute (target burst suppression).
**Other options for RSE in nonintubated patients
i. Valproate 20–40 mg/kg IV (if not already given).
ii. Lacosamide 200-400 mg IV.
iii. Topiramate 200–400 mg orally/nasogastrically.
iv. Other anticonvulsants listed earlier if not already given.
1. Cardioembolic (29.1%).
2. large-artery atherosclerosis(16.3%).
3. lacunar infarcts(15.9%).
4. Unknown (36.1%).
5. Other (2.6%).
Treatment
Permissive hypertension
Super-refractory status epilepticus
Secondary prevention
Seizure prophylaxis
Thrombolysis
Defined as failure to continous anesthetic agent after 24-48 hrs of burst suppression or termination of continuous EEG seizures.
A- Treatment is typically reinitiation of continuous anesthetic
Agents used for RSE:
B- Ketamine, an N-methyl-d-aspartate (NMDA) receptor antagonist, may also be considered. Ketamine may cause emergence psychosis and hallucinations, for which midazolam may help.
C- Patients should have a workup for causes of super-refractory status epilepticus (e.g., NMDA receptor antibody encephalitis, paraneoplastic syndromes, infectious encephalitis).
Mechanical thrombectomy
1- Thrombolysis
Nonpharmacologic therapies
Alteplase
0.9 mg/kg (max. 90mg)within 4.5 hrs of symptoms onset.
-10% of total dose as IV bolus.
-followed by 90% as 60-minute intravenous infusion.
a. ketogenic diet : limiting medication and nutrition to low carbohydrate content.
-Exact mechanism of action is unknown, but may increase sequestration of glutamate and decrease reactive oxygen.
-benefits occure within 1-3 months.
-modify diet targeting fat to carbohydrate plus protein in a 4:1 or 3:1 ratio.
b. Vagus nerve stimulation.
c. Surgical management.
d. Hypothermia.
Some tips about treatment of SIADH
Typical Inclusion/Exclusion Criteria for IV Alteplase
-Treatment of choice is fluid restriction.
-Treatment of SIADH can be difficult in some cases e.g. SAH & TBI.
-When treating ICP or cerebral vasospasm,the priority to maintain euvolmia to optimize CPP.
-Hypertonic saline solutions were commonly & most effectively increase serum sodium.
Considerations for Rapid Correction of Hyponatremia
1. Recommended increase in serum Na conc. Is 0.5 mEq/L/hr or less.
2. Patients with chronic hyponatremia may need to be corrected more slowly because of the equilibration of brain electrolytes.
3. Patients with acute hyponatremia may tolerate quicker correction.
4. Quicker correction in patients with severe symptoms (coma, seizures) may be prudent – Up to 1–2mEq/L/hr for first few hours.
5. Rapid correction necessitates frequent serum sodium monitoring (e.g., every 4 hours) to avoid overshoot or too rapid correction.
6. Too-rapid correction may result in osmotic demylination syndrome.
Routine approach should be limit Na increase to 12mEq/L in first 24 hours or less than 18 mEq/L in the first 48 hours.
CNS infection
Common Equations Used for Sodium Correction in Hyponatremia
2- permissive hypertension
a. reduction in blood pressure after thrombolysis is needed in the first 24 hrs after the onset of stroke.but,catiously to avoid hypotension or underperfusion of infarcted area (less than 15% blood pressure lowering).
b. Recommended to treat blood pressure in patients who do not receive thrombolytics if it exceeds 220/120
Hypernatremia
Case Selection
1. recommended in adult with CSF shunt.
-or ventriculostomy infections for difficult to eradicate
pathogens .
-or for patients who cannot undergo the surgical component of therapy.
2. May be also in patients receiving systemic therapy who have not cleared CSF cultures after 3–4 days.
3. Not recommended for neonatal or infant central nervous system (CNS) infection
Epidemiology:
1. Na greater than 150 mEq/L.
2. SAH up to 22%.
3. TBI up to 21%.
Diagnosis :
Laboratory tests: serum Na, serum osmolality, urine Na, urine osmolality & urine volume.
3- Seizure prophylaxis:
Appropriate Dosing
Use of anticonvulsant medications for seizure prophylaxis is not indicated after ischemic stroke.
4- Mechanical thrombectomy and neuroendovascular interventions for ischemic stroke:
a. Neuroendovascular devices may be used to remove or disrupt clot to facilitate recanalization.
b. No difference in safety outcomes when comparing usual care with usual care plus mechanical
thrombectomy
1. IV plus intraventricular is probably superior to intravenous or intraventricular alone.
2. Use preservative-free formulations.
3. Do not use diluents containing dextrose, whenever possible.
4. Do not use medications to lower the seizure threshold e.g. B-latams.
5. Daily dosing needs to adjust according to the amount of CSF drainage from external ventricular drain.
5- Secondary prevention
Various Antimicrobials and Doses for Intraventricular Administration
a. initiate (325mg /day,then 81-325mg/day) ,highly intense statin & intensive blood pressure regimen is necessary.but, Aspirin should not be initiated within 24 hours of alteplase.
b. Clopidogrel 75 mg daily is also an option in patients whose aspirin therapy has failed or who have
an aspirin allergy.
c. Aggrenox (dipyridamole/aspirin) and ticagrelor plus aspirin (less than 100 mg) are also effective alternatives to aspirin for secondary prevention.
d. hypertension: threshold to treat high blood pressure is greater than 140/90 mmHg.
*typical blood pressure goal is less than 130/80 mm Hg.
e. atrial fibrillation
i. Rate or rhythm control.
ii. Anticoagulation (warfarin, direct-acting oral anticoagulants)
iii. Typically, anticoagulant therapy is delayed until at least 5–14 days after stroke to reduce the risk of hemorrhagic conversion.
iv. Avoid using loading doses of warfarin.
f. Carotid artery stenosis:
Stent versus endarterectomy (usually for patients with greater than 70% blockage and/or clinically evident symptoms)
i. Aspirin 81–325 mg daily after endarterectomy
ii. Dual antiplatelet therapy should be given for 3 months if stent placement is required, followed by one antiplatelet agent thereafter.
g. Control of diabetes mellitus
Antiplatelets
E.g. Asprin,clopidogrel,dipyridamol
-Platelet transfusion infusion (usefulness is uncertain).
-Consider desmopressin 0.4 mcg/kg IV.
S.E. Pulmonary edema or transfusionrelated
reaction.
Unfractionated heparin
Protamine (1 mg of protamine for each 100 units of heparin infused within the past 2–3 hr).
Low molecular weight heparins
Protamine 1 mg for each 1 mg of enoxaparin (within 8 hr of last dose).
S.E. Hypotension, hypersensitivity
Andexanet Alfa Dosing Based on Factor Xa Inhibitor Dose
Platelet transfusion:
INTRACEREBRAL HEMORRHAGE
Causes
*Two prospective studies suggest that platelet transfusion for patients taking antiplatelet agents with new ICH is harmful.
*Patients in these studies have small stable ICH , basal ganglia hemorrhage which non operative.
*Platelet transfusion is likely indicated for patients who:
i. Have an urgent need for surgery or a ventriculostomy and have abnormal platelet function tests.
ii. Have a large ICH, receiving antiplatelet agents and requiring neurosurgery.
iii. Have acute neurologic decline with an intracranial hemorrhage.
Direct thrombin inhibitor
Diagnosis
E.g. Argatroban,dabigatran,bivalurudin
Idarucizumab (praxbind) 5g IV once.
-repeat dose in patients with high DTI exposure or poor renal function
-If hemostasis is not achieved:
4F-PCC 25–50 units/kg or activated 4F-PCC (FEIBA) 25–50 units/kg.
S.E. -Idarucizumab approved in late 2015 –antibody spicific for dabigatran .
-thrombosis ,limited data.
1.Chronic/poorly treated hypertension
2. Oral anticoagulant use
3. Cocaine/other stimulant use
4. Ischemic stroke with hemorrhagic transformation
5. Chronic alcohol intake
6. Brain tumor
7. Arteriovenous malformation
8. Amyloid angiopathy
a. Neurologic examination
b. Vital signs
c. NIH Stroke Scale and/or GCS score
* Imaging and other tests
a. CT or MRI scan of the brain
b. CT angiography or contrast-enhanced CT (to help identify patients at risk of hematoma expansion and to evaluate for underlying structural lesions)
c. Medication history to identify agents that might produce coagulopathy
d. laboratory tests.
e. Blood glucose
f. INR
g. CBC
Factor Xa inhibitors
Clinical Impact:
Anticoagulant reversal
Death or major disability occurs in around 50% of patients.
Treatment :
Platelet transfusion
Anticoagulant reversal
e.g.Apixaban,rivaroxaban ,fondaparinox
Andexanet alfa (Andexxa)
low dose(400 mg IV) or high dose(800 mg IV).
or 4F-PCC 25–50 units/kg.
or activated 4F-PCC (FEIBA) 25–50 units/kg.
S .E. -Rebound anti-Xa therapeutic concentrations within 2 hr of infusion completion.
-thrombosis ,limited data.
Argatroban,dabigatran,bivalurudin
Direct thrombin inhibitor
Apixaban,rivaroxaban ,fondaparinox
Factor x antagonist
Warfarin
Vit. K antagonist
Unfractionated heparin,low molecular weight heparin
Asprin,clopidogrel,dipyridamol
antiplatelets
Warfarin
INR < 4 4F-PCC(prothrombin complex concentrate e.g. cofact) 25 units/kg.
INR 4–6 35 units/kg.
INR > 6 50 units/kg + vitamin K 10 mg IV
Alternative :
FFP (fresh frozen plasma) 10-15 ml/kg+vitamin k 10 mg IV.
S.E. Thrombosis, anaphylactoid reaction(vitamin K), pulmonary edema, or transfusion-related reaction (FFP)