Seizure Medications in ICU
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Questions and Answers

What is the preferred benzodiazepine for acute seizure cessation due to its longer duration of action?

  • Lorazepam (correct)
  • Phenobarbital
  • Diazepam
  • Midazolam

    • Which medication acts as a prodrug of phenytoin and has fewer infusion-related side effects?

  • Lacosamide
  • Valproic Acid
  • Levetiracetam
  • Fosphenytoin (correct)

    • What risk is particularly associated with midazolam when used for continuous infusion?

  • Respiratory depression (correct)
  • Sedation
  • Cardiovascular instability
  • Neurotoxicity

    • Which mechanism is associated with levetiracetam in its role as an antiepileptic drug?

    <p>Inhibits neurotransmitter release by modulating SV2A</p> Signup and view all the answers

    In which situation is propofol typically indicated?

    <p>Refractory status epilepticus unresponsive to benzodiazepines</p> Signup and view all the answers

    Which medication should be avoided in patients with liver dysfunction or metabolic disorders?

    <p>Valproic Acid</p> Signup and view all the answers

    What is the primary risk associated with the use of thiopental or pentobarbital?

    <p>Ventilation requirement and hemodynamic instability</p> Signup and view all the answers

    Which antiepileptic drug is known for its favorable side effect profile and minimal drug interactions?

    <p>Levetiracetam</p> Signup and view all the answers

    What mechanism does phenobarbital primarily utilize in treating refractory status epilepticus?

    <p>Enhances GABA-A receptor activity</p> Signup and view all the answers

    Which of the following describes a critical monitoring consideration for patients receiving propofol?

    <p>Monitoring triglycerides and metabolic status</p> Signup and view all the answers

    What is the primary mechanism of action for ketamine in treating super-refractory status epilepticus?

    <p>Antagonizes NMDA receptors</p> Signup and view all the answers

    Which of the following agents is used specifically for seizures caused by isoniazid toxicity?

    <p>Pyridoxine (Vitamin B6)</p> Signup and view all the answers

    What is a key consideration when using corticosteroids and immunomodulators to treat seizures?

    <p>They require confirmation of autoimmune etiology</p> Signup and view all the answers

    Which potential side effect should be monitored when administering ketamine?

    <p>Tachycardia</p> Signup and view all the answers

    What role does continuous EEG monitoring have in the management of seizures?

    <p>It helps detect non-convulsive seizures</p> Signup and view all the answers

    Which of the following mechanisms do magnesium sulfate employ to aid in seizure management?

    <p>Blocks NMDA receptors</p> Signup and view all the answers

    What is the primary use of pharmacological treatment with magnesium sulfate in seizure disorders?

    <p>To manage hypomagnesemia seizures</p> Signup and view all the answers

    What does laboratory monitoring in the context of seizure treatment typically involve?

    <p>Regularly assessing drug levels and organ function</p> Signup and view all the answers

    What is the risk associated with many anticonvulsants and anesthetics noted in monitoring considerations?

    <p>Hypotension and respiratory depression</p> Signup and view all the answers

    Which clinical scenario would require the use of intravenous immunoglobulin (IVIG)?

    <p>Autoimmune encephalitis with confirmed diagnosis</p> Signup and view all the answers

    Which medication is indicated for absence seizures and is considered the drug of choice?

    <p>Ethosuximide</p> Signup and view all the answers

    Which medication is commonly used as an adjunctive therapy for focal seizures and also for neuropathic pain?

    <p>Gabapentin</p> Signup and view all the answers

    What is the preferred first-line benzodiazepine for managing status epilepticus in an emergency setting?

    <p>Lorazepam</p> Signup and view all the answers

    Which of the following medications is primarily used off-label for status epilepticus treatment?

    <p>Lacosamide</p> Signup and view all the answers

    Which antiepileptic medication is also used to treat bipolar disorder in addition to its seizure control properties?

    <p>Valproic Acid</p> Signup and view all the answers

    Which medication is specifically indicated for treating Lennox-Gastaut syndrome?

    <p>Clobazam</p> Signup and view all the answers

    Among the following, which medication is indicated for Dravet syndrome?

    <p>Cannabidiol</p> Signup and view all the answers

    Which anti-seizure medication is known for utilizing AMPA receptor antagonism?

    <p>Perampanel</p> Signup and view all the answers

    Which of the following medications is typically used for adjunctive therapy in generalized tonic-clonic seizures?

    <p>Topiramate</p> Signup and view all the answers

    Which medication requires careful monitoring due to its risk of causing significant sedation when used intravenously?

    <p>Midazolam</p> Signup and view all the answers

    What is the primary reason for using fosphenytoin over phenytoin in IV treatments?

    <p>Fosphenytoin has fewer infusion-related side effects.</p> Signup and view all the answers

    Which medication is considered the first-line treatment for neonatal seizures?

    <p>Phenobarbital</p> Signup and view all the answers

    In the context of SE treatment, what is the primary goal of using pentobarbital?

    <p>To achieve burst suppression in super-refractory cases.</p> Signup and view all the answers

    Which of the following treatments is specifically indicated for patients with anti-NMDA receptor encephalitis?

    <p>IVIG/Plasmapheresis</p> Signup and view all the answers

    What is a significant concern when using propofol for rapid seizure control?

    <p>It is linked to propofol infusion syndrome (PRIS).</p> Signup and view all the answers

    Which medication is contraindicated due to its high teratogenic risk in pregnant patients?

    <p>Valproic Acid</p> Signup and view all the answers

    What type of seizures is cannabidiol (Epidiolex) primarily used for?

    <p>Lennox-Gastaut and Dravet syndrome</p> Signup and view all the answers

    Which of the following medications is an NMDA receptor antagonist used in super-refractory status epilepticus?

    <p>Ketamine</p> Signup and view all the answers

    During which phase of status epilepticus should benzodiazepines be administered?

    <p>Initial Phase (0–5 minutes)</p> Signup and view all the answers

    Which anxiolytic is preferred for its route of administration in acute seizure situations?

    <p>Midazolam IM</p> Signup and view all the answers

    What is a key indicator of toxic levels of Dilantin (Phenytoin)?

    <p>Marked diffuse delta activity</p> Signup and view all the answers

    Which of the following is NOT a recognized effect of chronic use of AEDs?

    <p>Increased muscle strength</p> Signup and view all the answers

    Which side effect is specifically associated with Depakote (Valproic Acid)?

    <p>Fatal liver failure</p> Signup and view all the answers

    What common effect does Carbamazepine (Tegretol) have on EEG readings?

    <p>Diffuse slowing</p> Signup and view all the answers

    Which statement best describes the impact of acute intoxication with Dilantin (Phenytoin)?

    <p>Increased vestibular dysfunction</p> Signup and view all the answers

    What is a characteristic feature of Tegretol toxicity?

    <p>Drowsiness and ataxia</p> Signup and view all the answers

    What unusual withdrawal symptom is primarily associated with Lamictal (Lamotrigine)?

    <p>Rash</p> Signup and view all the answers

    Which effect is associated with therapeutic doses of Depakote?

    <p>Reduction or disappearance of generalized spikes</p> Signup and view all the answers

    What is a long-term consequence of chronic use of Phenytoin?

    <p>Chronic Phenytoin Encephalopathy</p> Signup and view all the answers

    What is the primary reason for the limited administration of RASH?

    <p>Potentially life-threatening effects</p> Signup and view all the answers

    During withdrawal from which of the following AEDs is a rash commonly observed?

    <p>Lamotrigine</p> Signup and view all the answers

    What EEG findings are typically seen in non-epileptic patients treated with RASH?

    <p>Widespread attenuation without slowing</p> Signup and view all the answers

    Which effect is NOT indicated for Topamax (topiramate)?

    <p>Designed for adult epilepsy only</p> Signup and view all the answers

    What kind of EEG changes can lithium cause?

    <p>Marked generalized slowing and spikes</p> Signup and view all the answers

    What side effect is commonly associated with Zarontin (ethosuximide)?

    <p>Lethargy and emotional instability</p> Signup and view all the answers

    Which of the following statements regarding lithium and EEG is true?

    <p>Triphasic patterns can be seen without indicating lesions</p> Signup and view all the answers

    In which scenario would EEG abnormalities be marked with lithium use?

    <p>During acute intoxication</p> Signup and view all the answers

    Which of the following is NOT considered a primary use of Zarontin?

    <p>Treatment of generalized tonic-clonic seizures</p> Signup and view all the answers

    Which of the following EEG findings is NOT associated with lithium intoxication?

    <p>Increased alpha activity</p> Signup and view all the answers

    What role does Zarontin specifically play in the treatment of epilepsy?

    <p>It is the main AED for absence epilepsy</p> Signup and view all the answers

    What is the primary action of SV2A modulators in the context of antiepileptic drugs?

    <p>Moderate neurotransmitter release to stabilize neuronal activity</p> Signup and view all the answers

    Which mechanism is NOT primarily associated with sodium and calcium channel blocking antiepileptic drugs?

    <p>Increasing the frequency of dopamine release</p> Signup and view all the answers

    How do AMPA receptor antagonists help in seizure management?

    <p>By blocking excitatory signals from glutamate</p> Signup and view all the answers

    What is a key function of carbonic anhydrase inhibitors in antiepileptic therapy?

    <p>They alter the pH balance in neurons</p> Signup and view all the answers

    Which antiepileptic drug primarily functions as a potassium channel opener?

    <p>Retigabine</p> Signup and view all the answers

    Which of the following accurately describes the function of ethosuximide in epilepsy treatment?

    <p>It specifically targets T-type calcium channels</p> Signup and view all the answers

    What effect does retigabine primarily have on neuronal activity?

    <p>Opens potassium channels to stabilize membrane potential</p> Signup and view all the answers

    What is the primary result of using GABA modulators in the brain?

    <p>Increased inhibitory signals within the central nervous system</p> Signup and view all the answers

    Which antiepileptic drug primarily functions as an NMDA receptor antagonist?

    <p>Perampanel</p> Signup and view all the answers

    How do sodium channel blockers primarily affect excessive neuronal firing?

    <p>By stabilizing the inactive state of sodium channels</p> Signup and view all the answers

    What is the primary effect of enhancing GABA's action in the context of antiepileptic drugs?

    <p>Hyperpolarization of neurons leading to decreased excitability</p> Signup and view all the answers

    In what way do NMDA receptor antagonists contribute to seizure control?

    <p>By reducing excitatory neurotransmission</p> Signup and view all the answers

    Which mechanism is involved in the activity of calcium channel blockers as AEDs?

    <p>Limiting calcium influx to dampen neurotransmitter release</p> Signup and view all the answers

    What role do benzodiazepines play in the context of GABA receptors as AEDs?

    <p>They enhance the effects of GABA by increasing chloride influx</p> Signup and view all the answers

    Which analogy best describes the action of sodium channel blockers in the control of seizures?

    <p>A brake that slows down moving vehicles</p> Signup and view all the answers

    Which drug is commonly associated with enhancing GABA availability as a mechanism to control seizures?

    <p>Valproic Acid</p> Signup and view all the answers

    How do NMDA receptor antagonists function in the context of excitatory neurotransmission?

    <p>They block excitatory signals</p> Signup and view all the answers

    What is the role of calcium channels specifically referenced in absence epilepsy?

    <p>To regulate neurotransmitter release</p> Signup and view all the answers

    Study Notes

    Medications for Seizures and Status Epilepticus (SE) in ICU

    • Benzodiazepines (First-Line):

      • Lorazepam (Ativan): Preferred for IV administration for status epilepticus. Rapid onset and longer CNS action, potential for respiratory depression and hypotension.
      • Midazolam (Versed): Used for continuous infusions in refractory cases, or for prehospital/early ICU management via intranasal, buccal, or IM routes. Effective for continuous infusions in refractory cases.
      • Diazepam (Valium, Diastat): IV or rectal gel for acute seizures.
      • Mechanism: Enhance GABA-A receptor activity for increased inhibition.

    • Anti-Epileptic Drugs (AEDs) (Second-Line):

      • Phenytoin/Fosphenytoin (Cerebyx): Fosphenytoin preferred due to better IV tolerance, second-line for SE if benzodiazepines fail. Blocks voltage-gated sodium channels. Monitor for arrhythmias and hypotension.
      • Levetiracetam (Keppra): Increasingly used as second- or adjunct therapy, well-tolerated with fewer drug interactions; IV form available. Modulates synaptic vesicle protein SV2A to inhibit neurotransmitter release.
      • Valproic Acid (Depakote): Alternative second-line, especially for focal seizures; IV form available. Increases GABA availability; modulates sodium and calcium channels. Avoid in liver dysfunction or metabolic disorders.
      • Lacosamide (Vimpat): Adjunct therapy for SE, particularly in focal seizures; IV form available. Enhances slow inactivation of sodium channels. Well-tolerated with minimal sedation.
      • Phenobarbital: Alternative for refractory cases, neonates, or when other agents fail, has a long half-life. Enhances GABA-A receptor activity and decreases glutamate release. Risks respiratory depression and sedation.

    • Anesthetics for Refractory Status Epilepticus:

      • Propofol (Diprivan): For RSE unresponsive to benzodiazepines and AEDs. Potentiates GABA-A receptor activity & inhibits NMDA receptors. Risk of Propofol Infusion Syndrome (PRIS) with prolonged use. Monitor triglycerides and metabolic status.
      • Thiopental/Pentobarbital: For RSE requiring barbiturate coma induction. Potentiation of GABA-A receptor activity, producing deep sedation/coma. Requires mechanical ventilation and close hemodynamic monitoring. Reserved for super-refractory status epilepticus (SRE).
      • Ketamine: Adjunct in super-refractory status epilepticus (SRSE) with potent NMDA receptor antagonism. Provides neuroprotective effects and additional analgesia. Increased risk of tachycardia and increased intracranial pressure.
      • Inhalational Agents (Isoflurane, desflurane): For refractory seizures in extreme cases.

    • Corticosteroids & Immunomodulators:

      • Methylprednisolone, IVIG, Plasmapheresis: Used for autoimmune encephalitis or immune-mediated seizures. Confirmation of autoimmune etiology is crucial.

    • Other Agents:

      • Pyridoxine (Vitamin B6): For seizures due to pyridoxine-dependent epilepsy or isoniazid toxicity. Corrects deficiency in the GABA synthesis cofactor.
      • Magnesium Sulfate: Used for seizures from eclampsia or hypomagnesemia. Blocks NMDA receptors & stabilizes neuronal membranes.

    ICU Monitoring and Considerations

    • Continuous EEG: Essential for detecting non-convulsive seizures and measuring treatment effectiveness.
    • Hemodynamic Support: Anticonvulsants & anesthetics can cause hypotension and respiratory depression. Close monitoring of blood pressure and oxygen saturation is critical.
    • Laboratory Monitoring: Regularly assess drug levels (e.g., phenytoin, valproic acid) and organ function (liver, kidneys). Monitor relevant lab values for renal and hepatic function.

    Status Epilepticus Treatment Protocol (Updated)

    • Initial Phase (0–5 minutes):

      • Benzodiazepines (Lorazepam IV, Midazolam IM/IV/intranasal/buccal, or Diazepam IV/rectal).

    • Second Phase (5–20 minutes):

      • Fosphenytoin, Valproic Acid IV, or Levetiracetam IV.
      • Lacosamide IV (alternative).

    • Third Phase (>20 minutes):

      • Continuous infusions: Midazolam, Propofol, or Pentobarbital. Consider continuous infusion therapy after 20 minutes to quickly and efficiently manage seizures.
      • Adjuncts: Ketamine, corticosteroids, or immune-modulating agents. Adjust treatment strategies to individual needs and seizure patterns.

    • Super-Refractory Phase (>24 hours):

      • Burst suppression strategy with continuous infusions of suitable agents.
      • Alternative therapies: Ketamine, inhalational anesthetics, or surgical options (e.g., VNS, responsive neurostimulation). Consider surgical options in severe cases, such as VNS or responsive neurostimulation.

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    Description

    Test your knowledge on the medications used for treating seizures and status epilepticus in the ICU. This quiz covers first-line benzodiazepines and second-line anti-epileptic drugs, including their mechanisms and side effects. Enhance your understanding of critical care pharmacology.

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