Definitions, Etiology, Pathophsiology
The minimum duration for a seizure to be classified as status epilepticus
5 minutes
The maximum loading dose of levetiracetam (in mg)
4500 mg
These are the 1st line agents for status epilepticus and their routes of administration
Benzodiazepines
Lorazepam is IV, diazepam is PR/IV, midazolam is IM, IN, buccal
This IV fluid should be avoided in patients on ketogenic diet
The preferred agent for pediatric refractory SE (third line therapy), according to the NYP algorithm
Midazolam infusion
This is the definition of super-refractory SE
SE that continues or recurs 24 hours or more after the onset of anesthesia, including those cases in which SE recurs on the reduction or withdrawal of analgesia
The target total phenytoin level for status epilepticus and non-status epilepticus
15-25 mcg/mL for status epilepticus
10-20 mcg/mL for non-status epilepticus
The conclusion of the ESETT Trial
Levetiracetam, fosphenytoin and valproate were found to be equally efficacious in improving patient responsiveness for status epilepticus
True or False: Suspensions are preferred over tablets for pediatric patients on a ketogenic diet
False
The FDA-approved antiepileptics for neonatal seizures
Phenobarbital and phenytoin
One potential etiology of seizures in each of the following populations: neonatal, pediatric, adult
Neonates: HIE, stroke, congenital, metabolic, infectious, drug-induced
Pediatric: genetic, trauma, febrile, metabolic, autoimmune
Adult: trauma, tumor, stroke, encephalitis, meningitis, metabolic, drug/alcohol induced
These are the benefits of fosphenytoin over phenytoin
Faster infusion rate, safer side effect profile (no purple glove syndrome), better compatibility
The alternative options for urgent control according to the NYP Adults SE Algorithm
Lacosamide, brivaracetam, phenobarbital
In a ketogenic diet, this % of calories should come from fat, protein, and carbohydrates each
65-75% fat, 20-25% protein, 5-10% carbohydrates
These are the risk factors for febrile seizures
NICU stays > 28 days, developmental delays, infection, family history of seizures
These are two neurotransmitters involved in the pathophysiology of seizures (Also classify them as inhibitory or excitatory)
- Glutamate: excitatory
- GABA: inhibitory
These are the site of actions for the following medications: phenytoin, lorazepam, levetiracetam, ketamine
Phenytoin - Na Channels
Lorazepam - GABA receptors
Levetiracetam - SV2A receptors
Ketamine - NMDA receptors
The other medication ketamine can be combined with to lower dose requirements
Simultaneous benzodiazepine infusion
These are two of the proposed mechanisms of a ketogenic diet in the management of epilepsy.
Increased levels of GABA, decreased levels of glutamate, increased production of BDNF, remodeling of gut microbiome, improvement of mitochondrial action, antagonize AMPA receptors, activation of KATP currents
The two treatment options for infantile spasms, and the side effect that requires a REMS program for one of them
Adrenocorticotropic hormone or prednisolone, vigabatrin
REMS for vision loss caused by vigabatrin
This is the pathophysiology of status epilepticus
After repeated seizures, GABA-a receptors are internalized
GABA-a receptors become inactive because they are no longer within reach of the neurotransmitter
In contrast, NMDA subunits are mobilized to the synaptic membrane and assemble into additional receptors
As a result, the number of functional NMDA receptors per synapse increases, whereas the number of functional GABA-a receptors decreases
The major side effects of propofol and monitoring parameters
Side effects - PRIS, hypotension, hypertriglyceridemia, pancreatitis
Monitor - TG, pH, HCO3, CPK, lipase, BP
A patient’s convulsions stop after lorazepam, but they remain unresponsive. What should be done next to determine whether seizure activity is continuing?
These are two interventions a pharmacist can make during order verification for the following med list for a patient on a ketogenic diet:
- acetaminophen chewable tablet
- senna tablet
- phenytoin suspension
- albuterol nebulizer
- amoxicillin suspension
acetaminophen to non-chewable tablet, phenytoin suspension to capsules, amoxicillin suspension to capsules
A 3-year-old child (15 kg) with history of epilepsy presents to the ED in status epilepticus. The patient already received rectal diazepam at home, followed by IV lorazepam on arrival in ED, with no response. The team orders levetiracetam 150 mg IV. This is what is wrong with the order.
150 mg would be 10 mg/kg which is too low for SE. The correct order would be 60 mg/kg IV -> 900 mg IV