Konvulsi Dan Hipertensi Pada Anak

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Status Epilepticus is defined as : Continuous seizure activity lasting longer than 30 minutes or two or more sequential seizures without full recovery of consciousness 50% as a symptom of an undelying diseases The remainder caused by complex febrile seizure and idiopathic epilepsy 2

Management To prevent or minimize the morbidity and mortality resulting from SE

Management divided into 3 phases: 1. Emergency Stabilization 2. Anticonvulsant Therapy 3. Diagnostic Work-up THE FIRST STEP IN MANAGING SE IS ASSESING THE PATIENT’S AIRWAY AND OXYGENATION 3

I.

Emergency Stabilization (ABC’s)

1. To prevent secondary hypoxic-ischemic brain injury 2. Establish an adequate airway, ensure adequate oxygenation and ventilation 3. Establish venous (or intraosseous) access and ensure effective circulating blood volume and perfusion pressure 4. Obtain blood for glucose determination

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Emergency Stabilization 5. Control fever 6. Pass a nasogastric tube; aspirate for toxicology 7. Assess cardiorespiratory status after anticonvulsants

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II. ANTICONVULSANT THERAPY A. Goals of Therapy 1. Rapidly terminate seizure activity 2. Prevent recurrences of seizure and secondary injury

B. Route of anticonvulsants These agents should be administered iv or io

Midazolam (MILOZR) is the only anticonvulsant that is rapidly effective when given im, rectally, buccally or nasally (5-10 minutes) 6

C. Benzodiazepines 1. Extremely rapid onset of action, short duration of

action 2. Include diazepam, midazolam, and lorazepam 3. Side effects: resp. depressions, sedation, and hypotension 4. A second longer acting drug (phenytoin/DILANTINR, phenobarbital) prevent recurrence. R The anticonvulsan effects of lorazepam (ATIVAN ) 7

D. Phenytoin (DILANTINR) 18 mg/kg iv 1. Effective for SE 2. To advantages over phenobarbital a. does not cause respiratory depression b. Causes much less sedation 3. Side effects: bradycardia and hypotension 4. Infused slowly (0,5-1 mg/kg/minute), max. 30 mg/kg up to 1000 mg BP and ECG should be monitor during infusion (hypotension and arrhythmias)

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E. Phenobarbital 15-20 mg/kg iv 1.

Effective anticovulsant, relative slow onset of action

2. Side effects: resp. depress., sedation, and hypotension 3. If benzodiazepine followed by phenobarb. may require intubation (respiratory depression) 4. Drug of chioce for neonatal SE max. 30 mg/kg up to 600 mg Thiopental induction dose 4-8 mg/kg for SE It is not an effective long-term anticonvulsant. Principal use in SE is to facilitate ventilation and subsequent

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ALGORITHM MANAGEMENT OF SEIZURE

0-5 minutes A, B, C resuscitation Vital sign Hemodynamic monitor Brief history Neurologic exam. Bloodwork (lab.) 5-10 minutes

NO

Diazepam IV: 0,3 – 0,5 mg/kg or Diazepam PR: BW <10 kg: 0,5 Repeat x 2 mg/kg every 5 BW >10 kg: 0,3 mg/kg, min or Midazolam? Diazepam PR: BW <10 kg: 5 mg BW >10 kg:10 mg

Seizure stop ?

Diazepam IV : 0,3 – 0,5 mg/kg or Diazepam PR: BW <10 kg: 5 mg BW >10 kg: 10 mg (midazolam 0,05-0,1 mg/kg iv) Seizure ? Hypoglycemia: D25stop 2 ml/kg

NO

YES Stop medication

YES Stop medication

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Seizure 10-15 minutesstop ? Prolonged Seizure Tend to SE

NO

Airway - Breathing – Circulation Sign of trauma/infection and Focal paresis Access intravenous line Examine: blood routine, glucose, electrolyte Phenytoin 15-20 mg/kg iv bolus 1 mg/kg/min

> 30 minutes

NO Status Epilepticus

Seizure stop ?

Phenobarbital 10-20 mg/kg IV (IM)

Seizure stop ?

YES 12 hrs after initial Phenytoin 5-7 mg/kg iv

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Seizure stop ? Refractor y Seizure

YES NO

Intubat e PICU

12 hrs after initial dose Phenobarbital 3-4 mg/kg im + Phenytoin 5-7 mg/kg iv

Midazolam 0,05-0,3 mg/kg iv, then maintenace 0,05-2 mcg/kg/min. or Thiopental 4-8 mg/kg iv or Propofol 1-2 mg/kg iv Respiratory depression → ventilator Muscle relaxant/paralyze CFAM - EEG CFAM= cerebral function analysis monitoring 12

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HYPERTENSIO SBP OR DBP > 95th Percentile for age on three measurements N HYPERTENSIVE EMERGENCIES SBP or DBP > 99th percentile for age with evidence of impaired end organ perfusion

HYPERTENSIVE CRISIS

A sudden severe increase in blood pressure to a level exceeding > 95th percentile for age

HYPERTENSIVE ENCEPHALOPAHTY

A set of symptoms including headache, convulsion and coma, associated with certain kidney diseases, pheochromocytoma, and drugs. 14

AGE

MODERATE HYPERTENSION (95TH-99TH %ILE)

SEVERE HYPERTENSION (>99TH % ILE)

< 1 year

Systolic >110 Diastolic >75

Systolic >120 Diastolic >85

1-9 years

Systolic >120 Diastolic >80

Systolic >130 Diastolic >85

10-12 years

Systolic >125 Diastolic >82

Systolic >135 Diastolic >90

12-18 years

Systolic >135 Diastolic >85

Systolic >145 Diastolic >90 15

Severe vasoconstriction causing ischemia to end organs and excessive afterload for myocardium. CNS effects: a. Encephalopathy b. Intracranial hemorrhage Left ventricular failure with pulmonary edema Acute renal failure Retinopathy 16

80-90% renal origin 1. Renal parenchymal or vascular disease 2. Vasculitis (e.g, SLE, polyarteritis nodosa) 3. Mineralocorticoid excess a. Corticosteroid use b. Adrenogenital syndromes c. Cushing’s syndrome 4. Catecholamine excess: a. Neuroblastoma b. Pheochromocytoma 5. Autonomic dysfunction

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The goal of acute parenteral therapy: 20% reduction in (MAP) MAP = (diastolic+1/3 [systolic-diastolic]) or Systolic - 2 diastolic : 3 (25% BP reduction within 1hrs) •

Direct vasodilators or sympathetic inhibitors

•

Relieve symptoms of end organ ischemia

•

May need β adrenergic blockade to prevent reflex tachycardia 18

Antihypertensive agent DRUG

DOSE

ROUTE

COMMENTS

Nifedipine

0.25-0.5 mg/kg

SL

Labetalol

0.1-0.25 mg/kg

IV

500µg/kg/min x 2min then 50µg/kg/min Nitroprussid 0.5µg/kg/min

IV

Predictable, can be drown up as liqiud from capsule for IV adm Slow IV push over 2 min, double every 10 min until effect is achieved (300mg total) then give last dose prn CI: in patients with asthma or who have received Ca++ channel blocker

Hydralazine 0.1-0.5 mg/kg Diazoxide 0.1-0.5 mg/kg

IV IV

Esmolol

IV

Intra-arterial monitoring reguired Repeat at 10-15 min intervals, causes hyperglycemia

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