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| From: | Fri Sep 28 0:00:00 PDT 2012 |
| To: | Fri Sep 28 8:00:00 PDT 2012 |
| nephondemand | #ecuimres #grandrounds 9/28: Keith Scott will present "Topics in Neurocritical Care". Will tweet live. Speaker profile: http://t.co/70q35Iy2 | |
| nephondemand | #ecuimres #grandrounds 9/28: Audience participation is requested. Follow link: http://t.co/jPUfVVhc | |
| nephondemand | #ecuimres #grandrounds 9/28: title slide http://t.co/Ocxy5op4 | |
| nephondemand | #ecuimres 9/28: no recording of #grandrounds today as per the desire of the speaker :( http://t.co/yVsQbkq9 | |
| MedPedsDoctor | #ecuimres gr8 to see that another institution is tweeting Grand Rounds. #meded | |
| nephondemand | #ecuimres #grandrounds 9/28: topics to discuss today= status epilepticus, SAH, bleeding p tpa, & brain dysfxn in severe illness | |
| ecuimchiefs | #ecuimres #grandrounds First topic: Status Epilepticus. Dr Scott feels this is a disorder that under treated (effectively). | |
| ecuimchiefs | #ecuimres #grandrounds Defined: seizure activity >5 minutes (previously >30 mins). | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus defined as lasting >5 minutes. Almost all sz's resolve within 5 min | |
| ecuimchiefs | #ecuimres #grandrounds Classified as: convulsive, non-convulsive, refractory (despite 2 anti epileptics). | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus classified into 3 groups: convulsive, non-convulsive, refractory (in spite of 2 AE drugs) | |
| ecuimchiefs | #ecuimres #grandrounds early phase of seizure = GABA dependent. Therefore use GABA agonist early! | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus the GABAnergic phase is the best time to intervene -- lasts 4 ~1 hr http://t.co/LaLgufqJ | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus after GABAnergic phase you enter the therapeutic resistance phase, mediated by glutamate | |
| ecuimchiefs | #ecuimres #grandrounds Status with convulsions has better prognosis than status without convulsions. | |
| ecuimchiefs | #ecuimres #grandrounds Goal of therapy is to stop the SEIZING, not the convulsions. | |
| nephondemand | RT @ecuimchiefs: #ecuimres #grandrounds Status w/convulsions has better prognosis than status w/o convulsions b/c u identify the sz sooner | |
| ecuimchiefs | #ecuimres #grandrounds New treatment paradigm: Initial therapy, Urgent control therapy, Refractory therapy. | |
| ecuimchiefs | #ecuimres #grandrounds Emergent: use benzos (extensive clinical experience). ie: IV lorazepam or IM midazolam | |
| ecuimchiefs | #ecuimres #grandrounds (or rectal diazepam) | |
| nephondemand | #ecuimres #grandrounds 9/28: #epilepticus 1st line therapy r GABA agonists = BDZs but evidence is Class III; IV Ativan, IM versed, PR valium | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus optimal initial dose = ativan 0.1 mg/kg upto 4 mg; repeat in 5 min; biggest fear is... | |
| ecuimchiefs | #ecuimres #grandrounds Lorazepam dosing: 0.1mg/kg. So 80 kg man --> 8mg. But neurocritical care society recommends max 4mg. | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus ...conversion from convulsive 2 nonconvulsive; this is the biggest problem w/underdosing | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus mortality increases when pt goes from convulsive to nonconvulsive status | |
| ecuimchiefs | #ecuimres #grandrounds Fear of under dosing status epilep is conversion from convulsive SE to non-convulsive SE (remember: worse prognosis) | |
| nephondemand | #ecuimres #grandrounds 9/28: #epilepticus best way 2 tell if pt is in nonconvulsive status: does he have interpretation of his environment? | |
| buyativanonline | #ecuimres #grandrounds 9/28: #status #epilepticus optimal initial dose = ativan 01 mg/kg upto 4... Buy Ativan Online -> http://t.co/HHzfXFoD | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus recommended dosages of midazolam IM or Valium PR. See pic http://t.co/wWinoazO | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus other recd drugs and their dosages; see pic http://t.co/K6XpxZEk | |
| ecuimchiefs | #ecuimres #grandrounds Patients treated with benzos actually suffered LESS resp suppression (intubation) than placebo. http://t.co/igvDCOB4 | |
| ecuimchiefs | #ecuimres #grandrounds Some evidence suggests valproate may have advantage over phenytoin: http://t.co/YFnQmZMU | |
| ecuimchiefs | #ecuimres #grandrounds If seizure activity >1 hour, pt is likely in Resistance phase of status. | |
| ecuimchiefs | #ecuimres #grandrounds Refractory drugs = continuous infusions (midazolam, propofol, pentobarbital). | |
| ecuimchiefs | #ecuimres #grandrounds we don't really use pentobarbital/phenobarbital anymore. Almost 100% develop VAP (has to do w/ WBC signaling). | |
| ecuimchiefs | #ecuimres #grandrounds After we've stopped a pts convulsions, why do we NOT monitor after via EEG to ensure seizure-free status? | |
| ecuimchiefs | #ecuimres #grandrounds Dr Scott asks why can we all read EKG to determine MI or not, but not do the same for EEG readings? | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus if convulsive, 30d mortality 19-27%, 90d is 19%; | |
| ecuimchiefs | #ecuimres #grandrounds Convulsive SE mortality: only 9-21% to hosp discharge, 30 days 19-27%. | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus convulsive morbidity: 11-16% have cognitive sequalae; 26% have some decline in fxnl status | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus delayed therapy for convulsive sz (1 hr) leads 2 mortality of ~45% | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus nonconvulsive 30d mortality 65% (die from cerebral edema), 90d mortality = no data | |
| ecuimchiefs | #ecuimres #grandrounds 8% vs 45% mortality if not treated within 1 hour. | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus nonconvulsive mortality =10% if sz lasts <10 hr; >10 hr, 85% mortality! | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus nonconvulsive morbidity- only 39% return to baseline at 3 months | |
| nephondemand | #ecuimres #grandrounds 9/28: #status #epilepticus the biggest take home point today : •TIME IS BRAIN• | |
| nephondemand | #ecuimres #grandrounds 9/28: moving on to SAH now | |
| nephondemand | #ecuimres #grandrounds 9/28: bleeding p #TPA tranexamic acid investigated as a thrombotic agonist 1.5-6g qd x 3w; good data from @bmj_latest | |
| ecuimchiefs | #ecuimres #grandrounds BP goals in ICH: no concrete data to guide us! | |
| nephondemand | #ecuimres #grandrounds 9/28: brain in critical illness #vagus nerve is really susceptible to inflammation, causing NT changes in brain |
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