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Finney JD, Schuler PD, Rudloff JR, Agostin N, Lobanov OV, Siegler J, Shah MI, Guterman EL, Chamberlain JM, Ahmad FA. Evaluation of the Use of Ketamine in Prehospital Seizure Management: A Retrospective Review of the ESO Database. PREHOSP EMERG CARE 2024:1-8. [PMID: 39058382 DOI: 10.1080/10903127.2024.2382367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 07/12/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVES Benzodiazepines are the primary antiseizure medication used by Emergency Medical Services (EMS) for seizures. Available literature in the United States and internationally shows 30% to 40% of seizures do not terminate with benzodiazepines called benzodiazepine refractory status epilepticus (BRSE). Ketamine is a potential treatment for BRSE due to its unique pharmacology. However, its application in the prehospital setting is mostly documented in case reports. Little is known about its use by EMS professionals for seizure management, whether as initial treatment or for BRSE, creating an opportunity to describe its current use and inform future research. METHODS We performed a retrospective review of 9-1-1 EMS encounters with a primary or secondary impression of seizure using the ESO Data Collaborative from 2018 to 2021. We isolated encounters during which ketamine was administered. We excluded medication administrations prior to EMS arrival and encounters without medication administration. Subgroup analysis was performed to control for airway procedure as an indication for ketamine administration. We also evaluated for co-administration with other antiseizure medications, dose and route of administration, and response to treatment. RESULTS We identified 99,576 encounters that met inclusion. There were 2,531/99,576 (2.54%) encounters with ketamine administration and 50.7% (1,283/2,531) received ketamine without an airway procedure. There were 616 cases (48%, 616/1,283) where ketamine was given without another antiseizure medication (ASM) and without any airway procedure. The remaining 667 (52%) cases received ketamine with at least one other ASM, most commonly midazolam (89%, 593/667). Adjusted for the growth in the ESO dataset, ketamine use by EMS professionals during encounters for seizures without an airway procedure increased from 0.90% (139/15,375) to 1.45% (416/28,651) an increase of 62% over the study period. CONCLUSIONS In this retrospective review of the ESO Data Collaborative, ketamine administration for seizure encounters without an airway procedure increased over the study period, both as a single agent and with another ASM. Most ketamine administrations were for adult patients in the south and in urban areas. The frequency of BRSE, the need for effective treatment, and the growth in ketamine use warrant prospective prehospital research to evaluate the value of ketamine in prehospital seizure management.
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Affiliation(s)
- Joseph Daniel Finney
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, Missouri
| | - Paul D Schuler
- Department of Emergency Medicine, School of Medicine, University of Missouri, Columbia, Missouri
| | - James R Rudloff
- Department of Pediatrics, Institute for Informatics Data Science and Biostatistics, Washington University in Saint Louis, St. Louis, Missouri
| | - Nicholas Agostin
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, Missouri
| | - Oleg V Lobanov
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Jeffrey Siegler
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Manish I Shah
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Elan L Guterman
- Philip R. Lee Institute for Health Policy Studies and Department of Neurology, University of California, San Francisco, California
| | - James M Chamberlain
- Pediatrics and Emergency Medicine, George Washington University, Washington, District of Columbia
| | - Fahd A Ahmad
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, Missouri
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Brinker ST, Yoon K, Benveniste H. Global sonication of the human intracranial space via a jumbo planar transducer. ULTRASONICS 2023; 134:107062. [PMID: 37343366 DOI: 10.1016/j.ultras.2023.107062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/25/2023] [Accepted: 05/30/2023] [Indexed: 06/23/2023]
Abstract
Contrary to conditioning a Focused Ultrasound (FUS) beam to sonicate a localized region of the human brain, the goal of this investigation was to explore the prospect of distributing homogeneous ultrasound energy over the entire brain space with a large cranium-wide ultrasound beam. Recent ultrasound preclincal studies utilizing large or whole brain stimulation regions create a demand for expanding the treatment envelope of transcranial pulsed-low intensity ultrasound towards Global Brain Sonication (GBS) for potential human investigation. Here, we conduct ultrasound field characterizations when transmitting pulsed ultrasound through human skull specimens using a 1-3 piezocomposite planar transducer operating at 464 kHz with an active single-element surface of 30 × 30 cm. Through computational simulation and hydrophone scanning methodology, ultrasound wave behavior and dose homogeneity in the brain space were evaluated under various trajectories of sonication using the planar transducer. Clinically relevant pulse parameters used for transcranial therapeutic ultrasound applications were used in the experiments. Simulations and empirical testing revealed that dose homogeneity and acoustic intensity over the brain space are influenced by sonication trajectory, skull lens effects, and acoustic wave reflections. The transducer can emit a spatial peak pulse average intensity of 4.03 W/cm2 (0.24 MPa) measured in the free-field at 464 kHz with electrical power of 1 kW. The simulation showed that approximately 99 % of the cranial volume was exposed with <30 % of the maximum external acoustic intensity being transmitted into the skull. The transmission loss across all sonication trajectories is similar to previously reported FUS studies. A marker for GBS dose homogeneity is introduced to score the ultrasound pressure field uniformity in the intracranial space. Results of this study identify the initial challenges of exposing the entire human brain space with ultrasound using a large cranium-wide sonication beam intended for global brain therapeutic modulation.
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Affiliation(s)
- Spencer T Brinker
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT, USA.
| | - Kyungho Yoon
- School of Mathematics and Computing (Computational Science and Engineering), Yonsei University, Seoul, South Korea
| | - Helene Benveniste
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT, USA
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Stavropoulos I, Pak HL, Valentin A. Neuromodulation in Super-refractory Status Epilepticus. J Clin Neurophysiol 2021; 38:494-502. [PMID: 34261110 DOI: 10.1097/wnp.0000000000000710] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SUMMARY Status epilepticus (SE) is a severe condition that needs immediate pharmacological treatment to tackle brain damage and related side effects. In approximately 20% of cases, the standard treatment for SE does not control seizures, and the condition evolves to refractory SE. If refractory status epilepticus lasts more than 24 hours despite the use of anesthetic treatment, the condition is redefined as super-refractory SE (srSE). sRSE is a destructive condition, potentially to cause severe brain damage. In this review, we discuss the clinical neuromodulation techniques for controlling srSE when conventional treatments have failed: electroconvulsive therapy, vagus nerve stimulation, transcranial magnetic stimulation, and deep brain stimulation. Data show that neuromodulation therapies can abort srSE in >80% of patients. However, no randomized, prospective, and controlled trials have been completed, and data are provided only by retrospective small case series and case reports with obvious inclination to publication bias. There is a need for further investigation into the use of neuromodulation techniques as an early treatment of srSE and to address whether an earlier intervention can prevent long-term complications.
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Affiliation(s)
- Ioannis Stavropoulos
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; and
| | - Ho Lim Pak
- Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Antonio Valentin
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; and
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Vidaurre J, Albert DVF, Parker W, Naprawa J, Mittlesteadt J, Idris AS, Patel AD. Improving time for administration of second-line antiseizure medications for children with generalized convulsive status epilepticus using quality improvement methodology. Epilepsia 2021; 62:2496-2504. [PMID: 34328222 DOI: 10.1111/epi.17026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Status epilepticus is a life-threatening neurological emergency. However, delay in median time to administration of second-line antiseizure medication exists. The aim of this quality improvement initiative was to decrease the average delay before fosphenytoin is administered for pediatric patients with generalized convulsive status epilepticus from 30 min (baseline data collected in 2013) to 15 min (50% reduction) by December 2015 and sustain this for 1 year. METHODS Our team conducted an analysis of baseline data for patients with continuous generalized convulsive status epilepticus who received fosphenytoin after receiving first-line benzodiazepine treatment. Using quality improvement methodology, areas for improvement were identified and specific interventions developed and implemented. A timeline of 15 min to initiate fosphenytoin administration after failure of first-line treatment was considered reasonable and achievable as a project aim. RESULTS A total of 199 patients were included in the dataset for the project. The database included patients aged 1 month and older. Ninety-eight percent of patients were between 1 month and 19 years of age. The gender distribution was even, with 54% of patients being White or Caucasian, 30% African American or Black, and 16% classified as "other." From January 2014 through December 2019, the average time before initiating fosphenytoin administration after failure of benzodiazepine therapy, for patients with generalized convulsive status epilepticus, decreased from 30 min (SD = 45.7) to 11.4 min (SD = 8.2, p = .043), thus reducing time to administration by 62%. SIGNIFICANCE Quality improvement methodology can be successfully applied to decrease administration time between first- and second-line antiseizure medications for status epilepticus.
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Affiliation(s)
- Jorge Vidaurre
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus, Ohio, USA
| | - Dara V F Albert
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus, Ohio, USA
| | - William Parker
- Quality Improvement Services at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jim Naprawa
- Section of Emergency Medicine, Benioff Children's Hospital, University of California, San Francisco, Oakland, California, USA
| | - Jackson Mittlesteadt
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus, Ohio, USA
| | - Ali-Shan Idris
- Division of Neurology, Mount Carmel Health System, Columbus, Ohio, USA
| | - Anup D Patel
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus, Ohio, USA
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Abstract
The emergent evaluation and treatment of generalized convulsive status epilepticus presents challenges for emergency physicians. This disease is one of the few in which minutes can mean the difference between life and significant morbidity and mortality. It is imperative to use parallel processing and have multiple treatment options planned in advance, in case the current treatment is not successful. There is also benefit to exploring, or initiating, treatment algorithms to standardize the care for these critically ill patients.
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Dag ZO, Isik Y, Turkel Y, Alpua M, Simsek Y. Atypical eclampsia and postpartum status epilepticus. Pan Afr Med J 2015; 20:17. [PMID: 25995814 PMCID: PMC4431409 DOI: 10.11604/pamj.2015.20.17.5831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 12/31/2014] [Indexed: 12/03/2022] Open
Abstract
Preeclampsia is an entity that may present from 20th week of gestation up to 48 hours postpartum and is associated with hypertension and proteinuria. Eclampsia is emergence of convulsions pre-eclampsia in pregnant women with signs and symptoms. Recent studies showed that in some women, preeclampsia and even eclampsia may occur without hypertension or proteinuria. Here, we present a case of 26 years old women who had an uneventful pregnancy until 30 weeks' of gestation. She had only proteinuria in laboratory tests and was diagnosed as status epilepticus in early postpartum period. Preeclampsia and eclampsia is related with serious fetal and maternal morbidity and mortality and may present with atypical course. The awareness of atypical cases of preeclampsia enhances early diagnosis and management which are critical to avoid feto-maternal complications.
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Affiliation(s)
- Zeynep Ozcan Dag
- Department of Obstetrics and Gynecology, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
| | - Yuksel Isik
- Department of Obstetrics and Gynecology, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
| | - Yakup Turkel
- Department of Neurology, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
| | - Murat Alpua
- Department of Neurology, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
| | - Yavuz Simsek
- Department of Obstetrics and Gynecology, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
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Kinney M, Craig J. Grand Rounds: An Update on Convulsive Status Epilepticus. THE ULSTER MEDICAL JOURNAL 2015; 84:88-93. [PMID: 26170482 PMCID: PMC4488931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/24/2015] [Indexed: 11/01/2022]
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Emergent EEG in the emergency department in patients with altered mental states. Clin Neurophysiol 2012; 123:910-7. [DOI: 10.1016/j.clinph.2011.07.053] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 07/20/2011] [Accepted: 07/21/2011] [Indexed: 11/21/2022]
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Mastrangelo M, Celato A. Diagnostic work-up and therapeutic options in management of pediatric status epilepticus. World J Pediatr 2012; 8:109-15. [PMID: 22573420 DOI: 10.1007/s12519-012-0348-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 02/06/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Status epilepticus (SE) is a life-threatening neurologic disorder comprising prolonged and unremitting crisis, and two or more series of seizures without complete intercritical recovery. DATA SOURCES We reviewed the literature through a Pubmed/Medline research using key words including status epilepticus, antiepileptic drugs and children, in order to revise and compare international/national protocols and to examine pediatric guidelines in SE management. RESULTS Neurologic impairment and SE etiology seem to be the most independent risks for mortality. A deep semiologic evaluation is essential to addressing diagnostic work-up. Ematochemical parameters, plasma levels of antiepileptic drugs and clinically oriented toxic/metabolic screening should be mandatory for investigating both causes and effects of SE. Electroencephalography is clearly helpful to characterize focal from generalized SE and to distinguish epileptic events from pseudoseizures, and it is deal to find nonconvulsive SE. Neuroimaging techniques could detect epileptogenic lesions (such as cortical malformations, tumors, demyelinating disorders or strokes) but are common in practice to find negative or controversial results. Pharmacologic management can be essentially arranged in three stages: benzodiazepines for early SE (lasting less than 30 minutes), phenytoin/fosphenytoin, phenobarbital, valproate, levetiracetam or lacosamide for established SE (30-90 minutes), and anesthetics for refractory SE (more than 90 minutes). CONCLUSIONS Status epilepticus is the most common neurologic emergency in childhood. A systematic diagnostic work-up and a three steps based therapeutic approach is required at this age.
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Affiliation(s)
- Mario Mastrangelo
- Department of Pediatrics, Child Neurology and Psychiatry, La Sapienza-University of Rome, Rome, Italy.
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Abstract
Status epilepticus is a common neurological emergency in childhood and associated with significant morbidity and mortality. Status epilepticus (SE) has been defined as continuous seizure activity lasting more than 30 min or 2 or more seizures in this duration without gaining consciousness between them. However, the operational definition has brought the time down to 5 min. Management can be broadly divided into initial stabilization, seizure termination, and evaluation and treatment of the underlying cause. Diagnostic evaluation and seizure control should be achieved simultaneously to improve outcome. Seizure termination is achieved by pharmacotherapy. Benzodiazepines are the first line drugs for SE. Commonly used drugs include lorazepam, diazepam, and midazolam. In children without an IV access, buccal or nasal midazolam or rectal diazepam can be used. Phenytoin as a second line agent is usually indicated when seizure is not controlled after one or more doses of benzodiazepines. If the seizures continue to persist, valproate, phenobarbitone or levetiracetam is indicated. Midazolam infusion is useful in refractory status epilepticus. Thiopentone, propofol or high dose phenobarbitone are considered for treatment of refractory status epilepticus. Prolonged SE is associated with higher morbidity and mortality. Long term neurological sequelae include epilepsy, behavioural problems, cognitive decline, and focal neurologic deficits.
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Eue S, Grumbt M, Müller M, Schulze A. Two years of experience in the treatment of status epilepticus with intravenous levetiracetam. Epilepsy Behav 2009; 15:467-9. [PMID: 19616482 DOI: 10.1016/j.yebeh.2009.05.020] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Revised: 05/22/2009] [Accepted: 05/23/2009] [Indexed: 11/24/2022]
Abstract
Since its introduction in 2006, 43 patients with various forms of status epilepticus (SE) have been treated with the intravenous formulation of levetiracetam (LEV) in our clinic. After ineffective treatment with benzodiazepines, intravenous LEV was administered as a short infusion (nonconvulsive and subtle SE) at a dose of 1000 or 2000 mg. In cases of convulsive SE, a fractionated injection of 1000 or 2000 mg was used. When the results for both are combined, SE could be terminated in 19 of 43 patients. Intravenous LEV was more effective in simple focal SE (3/5), complex focal SE (11/18) and myoclonic status (2/2) than in nonconvulsive (2/8) and subtle (1/2) SE. In no case was (secondarily) generalized convulsive status epilepticus (0/8) terminated. Intravenous LEV was also well-tolerated when injected in fractionated form. No severe adverse reactions were observed. As a result of this investigation, intravenous LEV in moderate doses may represent an efficacious and well-tolerated alternative for the treatment of focal (simple and complex focal) and myoclonic SE. Further investigations are needed to confirm this assumption as the patient numbers are quite low.
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Affiliation(s)
- S Eue
- Department of Neurology, Klinikum Bernburg gGmbH, Kustrenaer Strasse 98, Bernburg, Germany.
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