Ggulyra da status epileptikus
Tea tavartkiladze
Thanks to Edward P. Sloan, MD, MPH,
FACEP
Kklinikuri istoria
37w. Mmamakaci
033
generalizebuli tonur-klonuri krunCxva
saxlSi
moixsna diazepami i/v
med; fenobarbitali, dilantini
ar icavs reJims
emerjensSi
post-iqtaluri periodi
fok.nevr cvlilebebi ar aris
travmuli dazianeba, toqsikologiuri datvirTva
ar aris
ment statusi normaluri
aReniSna ganmeorebiTi gulyra
Semdeg?
mTavari kiTxvebi
gulyra da status epileptikus Soris sxvaoba
romeli protokolebiT vixelmZRvaneloT
ACEP guidelines
Eepidemiologia da klasifikacia
epilefsia 1/150
EerT epileptikze 4 emerjensSi viziti
weliwadSi
gulyra
• Sz = abnormal neuronal
discharge with recruitment
of otherwise normal
neurons
• Loss of GABA inhibition
paTofiziologia
Kkompensirebuli procesebi 40-60 wT-is
ganm, pasuxobs cns gaZlierebuli
metabolizmis moTxovnebs (SBP, CBF ↑↑)
40-60 wT-is Semdeg (SBP, CBF
klebulobs)
cns qsovilis nekrozi
paTofiziologia
• Glutamate toqsiuri mediatori
• cns nekrozi
• temp. HTN,, rhabdomiolizi,
hiperkarbia, hipoqsia, infeqcia
Mment statusi 20-40 wT-si unda
gamoswordes,
Tu pacienti isev komaSia vifiqroT
subtle SE & EEG
status epileptikus
Ggulyra 5-10 wuTi
Oori gulyra luciduri intervalis gareSe
klasifikacia
generalizebuli-orive hemisfero
parcialuri-erTi hemisfero
Generalizebuli gulyra
Kkonvulsiuri tipis tonur-klonuri
Aarakonvulsiuri tipis - absens gulyra
generalizebuli gulyra
Ppirveladi generalizebuli gulyra- iwyeba
rogorc tonur-klonuri
Mmeoradi generalizebuli- tonur-klonuri
krunCxva arakonvulsiuri parcialuri
gulyrisagan (aura xSiria)
Pparcialuri (erTi hemisfero)
martivi parcialuri (cnobiereba naTeli)
rTuli parcialuri (cnobiereba ar aris naTeli)
Gparcialuri gulyris specifiuri tipebi
Aabsens - petit mal
Pparcialuri - jeksonis, fokaluri motoruli
Kkompleqsuri parcialuri - safeTqlis wili,
fsiqomotoruli
status epileptikus klasifikacia
GCSE: NoN
Generalized convulsive SE
Mimdinareobs tonur-
klonuri motoruli
GCSE
aqtivobiT
NoN GCSE tipebi
Non-convulsive SE:
o Absence SE
o Complex-partial SE
• Subtle SE:
o Ggeneralizebuli konvulsiuri stat.
epileptikus
o koma, persistentuli iqtaluri periodi
o cudi prognozi (letaloba 50%)
refraqtoruli status epi.
ar eqvemdebareba pirveli rigis arCevis
preparatebiT mkurnalobas(benzo, fenitoini)
cns mZime paTologia
gvxvdeba 6-9%-Si
Subtle SE?
mkurnaloba
protokolebis, kvlevebis simcire, ar arsebobs
erTi wesi
VA Coop Study
Treiman, NEJM 1998
Lorazepam 65%,
phenobarbital 58%
Diazepam and phenytoin 56%
Phenytoin alone inferior 44%
No use of fosphenytoin
SE Review Article
• Lowenstein, NEJM 1998
• Lorazepam, phenytoin,
phenobarbital
• Midazolam an propofol i.v
gadasxmebi
• EMS: i.m. midazolam
Ppediatriuli SE Protocol
Status Epilepticus Working Party
British protocol, Arch Dis Child,
2000
• Lorazepam, a phenytoin,
paraldehyde
• General anesthesia
mtkicebulebiTi medicina
• Strength (Class) of evidence
I: Randomized, double blind interventional
studies for therapeutic effectiveness;
prospective cohort for diagnostic testing or
prognosis
II: Retrospective cohorts, case control
studies, cross-sectional studies
III: Observational reports; consensus
reports
• Evidence strength downgraded if flawed
methodologically
ACEP Seizure/SE
mtkicebulebiTi medicina
rekomendaciis sxvadasxva done
o A (Standard): High degree of certainty
based on Class I studies
o B (Guideline): Moderate clinical certainty
based on Class II studies
o C (Option): Inconclusive certainty
based on Class III evidence, consensus
lab kvlevebi axladaRmocenebuli
gulyra
G Tu pac. gulyris Semdgomi (postiqtaluri) periodi
gagrZelda cota xans, ris Semdegac pacientis
mdgomareoba, statusi daubrunda sawyiss,
garTulebebi ar aReniSna.
Labs
• Level B recommendations:
glukoza sisxlSi
Eeleqtrolitebi
fexmZimobis testi
LP T.t kt-s Semdeg imunodeficitis
dros
Neuroimaging
axladaRmocenebuli gulyra
Level B recommendations
T.t k.t, Tu kt ver xerxdeba, pacientis
hospitalizacia an riskis Sefasebis Semdeg
ambulatoriulad viziti nevrologTan
Ddispozicia
axladaRmocenebuli gulyra
Level C recommendations
pacientebi norm. kt kvleviT, norm lab.
monacemebiT, romelTac ar aReniSnebaT fok. nevr,
cvlilebebi SesaZlebelia gaeweron emerjensidan,
nevrologis ambulatoriuli meTvalyureobis qveS
pacientebi norm. kt kvleviT, norm lab.
monacemebiT, romelTac ar aReniSnebaT fok. nevr,
cvlilebebi ar saWiroeben antiepilefsiur mkurnalobis
daniSvnas
Sz/SE:mkurnaloba
Level C recommendation
pacientebSi romlebic saWiroeben antiepilefsiur
mkurnalobas, medikamentebs viwyebT
emerjensSi
Sz/SE
romeli medikamentebi gamoviyenoT rodesac pirveli rigis
arCevis preparatebi ar arian efeqturi
Level C recommendation:
o iv: “maRali doza phenytoin-is,”
phenobarbital, valproic acid,
midazolam infuzia, pentobarbital
infuzia, an propofol infuzia.
Sz/SE: EEG
Level C recommendation:
onon-convulsive SE
osubtle convulsive SE,
oa long-acting paralytic,
o drug-induced coma.
ACEP Summary
Aar arsebobs Level A recommendation
standartul mkurnalobas ar gansazRvravs
dafuZnebulia mtkicebulebiT medicinaze
Stat SE Protocol: 0-90 Min
oTxi 30 min periodi
• 0-30 ABCs, Benzos
• 30-60 Phenytoins
• 60-90 Phenobarb,
Valproate
Stat SE Protocol: 90-120 Min
• 90-120grZeldeba
antiepilefsiuri med.
i.v. infuzia
• CT, neiro konsultacia
• ICU
• EEG monitoringi
ED Patient Management
• Lorazepam 2 mg IVP x 6 25 min
generalizebuli krunCxva grZeldeba
• Fosphenytoin 1 gram 10 wT-is
ganmavlobaSi
• Fosphenytoin 500 mg 5wT-is
ganmavlobaSi
krunCxva dasrulda
ED Diagnostic Evaluation
• ukontrasto CT norma
• metaboluri testebi norma
• toqsikologiuri skriningi uaryofiTi
• sub-Terapiuli fenitoinis done
• sub-Terapiuli fenobarbitalis done
• Diagnosis: Status Epilepticus
