44 alte urgente neurologice
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44 Alte Urgente NeurologiceTRANSCRIPT
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04/21/23
Abordarea in urgenta si gestionarea pacientului cu status epilepticus
Antoniu Brinzeu
Program cofinantat din Fondul Social European prin Programul Operational Sectorial Dezvoltarea Resurselor Umane 2007-2013
INVESTESTE IN OAMENI!
Continutul acestui material nu reprezinta in mod obligatoriu pozitia oficiala a Uniunii Europene sau a Guvernului Romaniei
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Status epilepticus
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Definitie
S. E . Se defineste de catre OMS ca :
“ “ o stare caracterizata printr-o criza o stare caracterizata printr-o criza de epilepsie care persista suficient de de epilepsie care persista suficient de mult sau care se repeta la intervale mult sau care se repeta la intervale suficient de scurte pentru a crea o suficient de scurte pentru a crea o conditie fixa si durabila conditie fixa si durabila “- 30 “- 30 minute….
Tratament dupa 10‘ de
convulsii
Tratament dupa 10‘ de
convulsii
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Definitie
3 crize repetate fara interval liber intre ele - SE
3 crize repetate fara interval liber intre ele - SE
Crize repetate in serie dar cu reluarea cunostiintei -
“amenintare de SE”
Crize repetate in serie dar cu reluarea cunostiintei -
“amenintare de SE”
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Forme electroclinice de SE
Clasificare dupa patru criterii :
1.Miscarile anormale2.Tulburarile de cunostiinta3.Traseul EEG4.Evolutia
1. Crize convulsive
tonico – clonice generalizate
1. Crize convulsive
tonico – clonice generalizate
3. Crize convulsive SE cu activitate motorie
localizata - partiala
3. Crize convulsive SE cu activitate motorie
localizata - partiala
2. SE non convulsiv 2. SE non convulsiv
4. SE refractare
4. SE refractare
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Clasificare : SE convulsiv, generalizat
Motor : crize tonico – clonice bilaterale subintrante sau
apropiate
Motor : crize tonico – clonice bilaterale subintrante sau
apropiate
Vegetativ : sialoree , hipersecretie bronsica, tahicardie, tulburari de ritm , hipertermie,
bradipnee , acidoza
Vegetativ : sialoree , hipersecretie bronsica, tahicardie, tulburari de ritm , hipertermie,
bradipnee , acidoza
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Clasificare : SE convulsiv, generalizat
Constienta: coma intre accese Constienta: coma intre accese
EEG : descarcari care se succed si pot fuziona – activitatea motorie se modifica –
miscari fine , miscari doar oculare
EEG : descarcari care se succed si pot fuziona – activitatea motorie se modifica –
miscari fine , miscari doar oculare
SE este franc diagnostic
evident
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Clasificare : SE nonconvulsiv
Stare de rau epileptic non
convulsiv
•clinic nu se evidentiaza convulsii•EEG traseu de epilepsie ; accese cu succesiune rapida
Stare de rau epileptic non convulsiv
•clinic nu se evidentiaza convulsii•EEG traseu de epilepsie ; accese cu succesiune rapida
Bolnavul comatos - crize EEG ?!
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Clasificare : SE nonconvulsiv
Monitorizarea EEG a pacientilor comatosi ? !
Monitorizarea EEG a pacientilor comatosi ? !
Profilaxia medica- mentoasa
sistematica a convulsiilor ?!
Profilaxia medica- mentoasa
sistematica a convulsiilor ?!
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Clasificare : SE motor partial
Crizele partiale sau focale : cu sau fara pierdere de cunostiinta• Fara pierdere de cunostiinta - frecvent secundare ( tumori, malformatii arterio –venoase)•Pot evolua spre deficit motor postcritic, generalizare, coma
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SE refractar
10% din SE convulsivante tratate si
30 % din SE non convulsivante evolueaza
spre forma refractara
10% din SE convulsivante tratate si
30 % din SE non convulsivante evolueaza
spre forma refractara
Cauza •Tratament
intarziat •Substante inadecvate
La reanimation neurochirurgicale – Ravussin, Boulard, Bruder11
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Cauzele SE la adult
Cu antecedente epileptice :
•Epilepsie esentiala•Epilepsie posttraumatica •Etilism cronic•Oprirea tratamentului antiepileptic
Cu antecedente epileptice :
•Epilepsie esentiala•Epilepsie posttraumatica •Etilism cronic•Oprirea tratamentului antiepileptic
La reanimation neurochirurgicale – Ravussin, Boulard, Bruder12
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Cauzele SE la adult
SE inaugural •Encefalopatie ischemica sau anoxica •Hemoragie intracerebrala sau meningee•Tumori •Infectii : abces cerebral, meningita, encefalita•Insuficienta hepatica•TCC •Insuficienta multipla de organe •Toxemie gravidica•Embolie gazoasa
SE inaugural •Encefalopatie ischemica sau anoxica •Hemoragie intracerebrala sau meningee•Tumori •Infectii : abces cerebral, meningita, encefalita•Insuficienta hepatica•TCC •Insuficienta multipla de organe •Toxemie gravidica•Embolie gazoasa
La renimation neurochirurgicale – Boulard, Ravussin, Bisonnette13
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Evolutie si prognostic
Cresc :
•metabolismul cerebral •fluxul sanguin cerebral → dupa 30 ‘ exista o datorie de oxigen importanta•Hiperlactatemie•Hiperglicemie•Edem cerebral •Substante excitotoxice
Cresc :
•metabolismul cerebral •fluxul sanguin cerebral → dupa 30 ‘ exista o datorie de oxigen importanta•Hiperlactatemie•Hiperglicemie•Edem cerebral •Substante excitotoxice
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Evolutie si prognostic
Eliberare de radicali liberiOsmolaritate crescuta – prin depolarizare prelungita
ApneeAcidoza
HipertensiuneHipotensiune
Oprirea circulatiei
Eliberare de radicali liberiOsmolaritate crescuta – prin depolarizare prelungita
ApneeAcidoza
HipertensiuneHipotensiune
Oprirea circulatiei
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Evolutie si prognostic
SE tratat corespunzator:
Mortalitate - 5% la copii20% la adulti
SE tratat corespunzator:
Mortalitate - 5% la copii20% la adulti
Mortalitatea :Dependenta de
etiologieSE creste
mortalitatea in TCC si in hemoragiile
meningee si invers
Mortalitatea :Dependenta de
etiologieSE creste
mortalitatea in TCC si in hemoragiile
meningee si invers
Factori de gravitate:
Traumatismele cranio – cerebrale•HAS•Intarzierea tratamentului•Durata crizei•Rezistenta la tratament
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Tratamentul SE
Obiectiv: atingerea de concentratii terapeutice in creier pentru substantele anticonvulsivante
Obiectiv: atingerea de concentratii terapeutice in creier pentru substantele anticonvulsivante
Substante anticonvulsivante in SE:
1.Antiepileptice clasice : fenitoina, acidul valproic, fenobarbitalul2.Benzodiazepinele si anestezicele generale: propofol, thiopental3.Lidocaina
Substante anticonvulsivante in SE:
1.Antiepileptice clasice : fenitoina, acidul valproic, fenobarbitalul2.Benzodiazepinele si anestezicele generale: propofol, thiopental3.Lidocaina
Manualul Merck - Ed. XVIII04/21/23 17
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Tratamentul SE
Obiective :Obiective :1.Precizarea diagnosticului de SE – 10 ‘2.Prevenirea consecintelor cerebrale si sistemice3.Oprirea crizelor 4.Prevenirea recidivelor
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La reanimation neurochirurgicale – Ravussin, Boulard, Bruder
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Tratamentul SE
Mijloace: Mijloace: Notarea orei de debut Decubit lateral – pozitie de siguranta- canulaAdministrare de oxigen pe masca Abord venos periferic- perfuzie hidrosalina izotonicaMontarea elementelor de monitorizare :EKS, SpO2, TA
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Tratamentul SE
Administrare numai i.v. a med.anticonvulsivante:
Diazepam – 0,2 mg/kg/c i.v. bolus sauLorazepam – 0,1 mg/kg – max 2mg/min,max 8 mg
Fenitoin 18 mg/ kgc administrate in ritm de max 50 mg /min. – 1500 mg in 30 minute - Fosfenitoin
Fenobarbital -Gardenal 1000mg ( 5 fiole de 200 mg) i.v. in 20 min. Monitorizarea Monitorizarea
respiratieirespiratieiMonitorizarea Monitorizarea
respiratieirespiratieiLa reanimation neurochirurgicale – Ravussin, Boulard,
Bruder Manual Merck Ed XVIII04/21/23 20
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Acid valproic – intravenos - eficienta cel putin egala cu cea a fenitoinei
Levetiracetam- Kepra – forma i.v. in cazurile refractare
Topiramat- in stadiul investigational
Gabapentin
22Mihaela Simu – Curs de Neurologie
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Tratamentul SE
Inducerea anesteziei generale :Inductia cu propofol sau thiopentalAdministrare de succinilcolinaIntubatie traheala Ventilatie mecanica
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Tratamentul SE
Terapie intensivaTerapie anticonvulsivanta : asociere Monitorizare EEG
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Sindromul Guillain Barre – terapie intensiva Sindromul Guillain Barre – terapie intensiva
Sinonime: Polinevrita acuta idiopatica, Paralizie Landry,Poliradiculopatie
acuta demielinizanta
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Definitie
Polineuropatie :•acuta•inflamatorie •dobandita•rapid progresiva
Polineuropatie :•acuta•inflamatorie •dobandita•rapid progresiva
Slabiciune musculara→
Paralizii → insuficienta respiratorie acuta
Tulburari de sensibilitate periferica
Etiologie •mecanism autoimun declansat de •Infectii >50% : Campylobacter jejunii, virusuri ( enteric, citomegal, mononucleoza, herpes), •Operatii•Dupa 5 zile – 3 saptamani
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Forme cliniceForma comuna:
•slabiciune musculara simetrica, maxima la 3 saptamani (90% )•Fara afectare sfincteriana•ROT abolite
Forma comuna:
•slabiciune musculara simetrica, maxima la 3 saptamani (90% )•Fara afectare sfincteriana•ROT abolite
Forma cu IR severa 5-10% : necesita IOT si ventilatie mecanica
( paralizia muschilor respiratori)
Forma cu IR severa 5-10% : necesita IOT si ventilatie mecanica
( paralizia muschilor respiratori)
Forma cu tulburari vegetative severe( amenintatoare de
viata )
•Oscilatii tensionale•Tulburari de ritm•Secretie inadecvata de ADH•Staza gastrica•Retentie de urina•Modificari pupilare
Forma cu tulburari vegetative severe( amenintatoare de
viata )
•Oscilatii tensionale•Tulburari de ritm•Secretie inadecvata de ADH•Staza gastrica•Retentie de urina•Modificari pupilare
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Diagnostic
Clinic Clinic ++
EMG : EMG : la 2/3 din cazuriincetinirea conducerii nervoase
demielinizare segmentara
Examen LCR : Examen LCR : disociere albumino citologica ( poate intarzia 7 zile, absenta in 10 % din cazuri )
Clinic Clinic ++
EMG : EMG : la 2/3 din cazuriincetinirea conducerii nervoase
demielinizare segmentara
Examen LCR : Examen LCR : disociere albumino citologica ( poate intarzia 7 zile, absenta in 10 % din cazuri )
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Prognostic
Decese Decese < 2% a( USA)
Sechele motorii Sechele motorii diferite - la 3 ani :•30% la adulti•> 30% la copiiPolineuropatie cronica recurentaPolineuropatie cronica recurenta : 3-10% : 3-10%Recuperari complete la ceilalti
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Tratament
Internarea in TI – necesaraInternarea in TI – necesaraOxigen pe mascaMonitorizare : SpO2, puls,EKS, TAMonitorizarea : VEMS si CV – la 6-8 ore ?!!! IOT si ventilatie mecanica la VEMS < 15 ml / kgc
Pericol :•Hipoventilatie severa •Hipoxie •Oprirea circulatiei•Tulburari de ritm si vasculare
Pericol :•Hipoventilatie severa •Hipoxie •Oprirea circulatiei•Tulburari de ritm si vasculare
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Tratament
Prevenirea escarelor Prevenirea anchilozelor si atrofiilor muscularePrevenirea trombozelor
Tratament etiologic – nu exista ( e tardiv )Tratament patogenetic : Tratament patogenetic : este eficient , scurteaza durata atacului reduce complicatiile
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Tratament
•Plasmafereza: eficienta•Gamma globulinele iv. 400 mg /kg/zi timp de 5 zile – aceeasi eficienta•Combinarea metodelor nu este eficienta ( se elimina gamma glogulinele)•Nu corticoizi in formele acute ( cresc frecventa complicatiilor )
Tratament patogenetic cat mai devreme !!!
Tratament patogenetic cat mai devreme !!!
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Miastenia gravis
Boala autoimuna: distrugerea receptorilor acetilcolinergici prin mecanism autoimun mediat
celular si prin anticorpi
Boala autoimuna: distrugerea receptorilor acetilcolinergici prin mecanism autoimun mediat
celular si prin anticorpi
Episoade de slabiciune musculara Insuficienta respiratorie acuta uneori
amenintatoare de viata
Episoade de slabiciune musculara Insuficienta respiratorie acuta uneori
amenintatoare de viata
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Miastenia gravis
1.Slabiciune musculara a membrelor: accentuata de efort Restabilire dupa repaus
2. ± semne oculare – 40 %
3. ± semne bulbare - voce, obstructie respiratorieIntensitatea ondulanta
1.Slabiciune musculara a membrelor: accentuata de efort Restabilire dupa repaus
2. ± semne oculare – 40 %
3. ± semne bulbare - voce, obstructie respiratorieIntensitatea ondulanta
Criza miastenica :
1.Tetrapareza grava amenintatoare de viata2.Insuficienta respiratorie severa3.Infectie declansatoare
Criza miastenica :
1.Tetrapareza grava amenintatoare de viata2.Insuficienta respiratorie severa3.Infectie declansatoare
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Diagnostic
Neurolog ! Semnele de slabiciune muscularaTestele cu anticolinesteraze injectabile : edrofonium ( in lipsa neostigmina ?)EMG : stimuli repetitivi – fatigabilitatea muscularaCT/ RMN toracic – timom ?
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Tratament Tratamentul insuficientei respiratorii : IOT + ventilatie
mecanica
Piridostigmina 30 – 60 mg /4-6 ore ( pana la 180 la 4 ore) enteral
sauNeostigmina i.v. ( 1 mg = 60 mg
piridostigmina enterala)- atropina, propantelina
Tratamentul infectiei declansatoare !!!
Tratamentul insuficientei respiratorii : IOT + ventilatie
mecanica
Piridostigmina 30 – 60 mg /4-6 ore ( pana la 180 la 4 ore) enteral
sauNeostigmina i.v. ( 1 mg = 60 mg
piridostigmina enterala)- atropina, propantelina
Tratamentul infectiei declansatoare !!!
1. Terapie respiratorie
2. Kineto3. Prevenirea
escarelor4. Prevenirea
tromboembolismului
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Tratament
1. Imunoglobulinele G 400 mg/kgc/zi 5zile ( eficiente in 1-2 saptamani dureaza 1-2 luni la 70 % din cazuri)
2. Corticosteroizii – tratament de intretinere – prednison
3. Imunosupresoarele : azathioprina 2,5 – 3,5 mg/kgc sau cyclosporina
4. Timectomia
1. Imunoglobulinele G 400 mg/kgc/zi 5zile ( eficiente in 1-2 saptamani dureaza 1-2 luni la 70 % din cazuri)
2. Corticosteroizii – tratament de intretinere – prednison
3. Imunosupresoarele : azathioprina 2,5 – 3,5 mg/kgc sau cyclosporina
4. Timectomia04/21/23 39
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Take home message ?!
Status epilepticus : sindrom grav, ameninta viatainterventie rapida, agresiva , tratament i.v. asociere de 2-3 antiepilepticeSindromul Guillain Barré : internare in TI, tratament patogenetic cat mai repede – gamma globuline, plasmafereza, nu asociere ! ( NU corticoterapie)Miastenia gravis : TI, diferentiere fata de SGB – tratamentul difera! (DA corticoterapie)
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