The effectiveness of therapy largely depends on the timing of its onset and is real in neuroresuscitation (intensive care) units and intensive care units. The drugs are administered intravenously or into the rectum, if necessary (the absence of forms for parenteral administration), the drug can be administered through a nasogastric tube into the stomach.
Diazepam is a first-line drug of choice, injected intravenously at a rate of 2.5 mg / min in adults at a dose of 10–20 mg, in children at a dose of 0.2–0.3 mg / kg. If necessary, after 10-20 minutes it can be re-entered. It is also possible to drip 100 ml of diazepam (500 mg) per 500 ml of 5% glucose solution at a rate of 40 ml / h. Effective use of 5-10 ml of a special solution for rectal administration.
A definite advantage is that diazepam is effective in all forms of ES. The shortcomings of the drug include a short duration of action, the risk of developing respiratory depression, cardiac activity, hypotension, especially with the rapid introduction in children.
Currently, another benzodiazepine, lorazepam, has found widespread use. Lorazem, in contrast to diazepam, which has a slow metabolism, is injected intravenously at the rate of 0.07 mg per 1 kg of body weight, if necessary, it can be re-administered (for adult patients after 10 minutes). The effect lasts about 12 hours. Further administration is contraindicated due to a sharp increase in tolerance.
Phenytoin is the means of the next choice in turn and is used if the ES is not stopped within 30 minutes. The drug is administered intravenously at a rate of 15-18 mg per 1 kg of body weight, children at a dose of 20 mg / kg at a rate of not more than 2.5 mg / min.
In Russia, the ampoule form of phenytoin is not registered, so the method of administering this drug through a nasogastric tube (tablets are crushed) at a dose of 20-25mg / kg is used. Repeated introduction can be carried out not earlier than in 1 day. only when monitoring the level of the drug in the blood (no more than 20 µg / ml). Phenytoin is effective in all ES, has a prolonged effect, does not inhibit the central nervous system, can be used for a long time. The disadvantages of the drug include delayed onset of action, nonlinear pharma-kinetics, the possibility of slowing down and heart rhythm disturbances, as a result of which ECG monitoring is necessary. Phenytoin is contraindicated in patients with atrioventricular block 1-2 degrees, sick sinus syndrome, as well as in the first 3 months. after myocardial infarction. The drug is absolutely contraindicated in porphyria, diseases of the bone marrow, as well as allergies to it.
Sodium thiopental (thiopentone) is a means of the third choice. The drug is administered in a dose of 100-250 mg intravenously for 20 seconds, then 50 mg every 2-3 minutes until the seizure stops, usually 3-5 mg / kg / h. Its advantages: high efficiency, potentially cerebro-protective effect, reduces intracranial pressure; disadvantages: a strong tendency to accumulation, reduction of cerebral blood flow, the development of tolerance is possible. Contraindicated in porphyria.
Simultaneously with anticonvulsant therapy, diagnostic studies are carried out to establish the etiology of status and control of cardio-respiratory function, antihypoxic therapy (oxygen 10 l / min), 5% glucose with thiamine is injected. In case of acidosis, 3-8% solution of sodium bicarbonate is administered under the control of blood pH. In case of arterial hypotension, dopamine 2-5 mcg / kg / min is used intravenously / in severe cases up to 20 µg / kg / min in severe cases.
If after 60–90 minutes from the onset of the status, epileptic seizures do not stop, the patient is transferred to controlled anesthesia with sodium thio-pental or hexenal under muscle relaxants and mechanical ventilation maintained for 12–24 hours after the last seizure.
With intracranial hypertension, mannitol, dexameta-zones (4 mg every 6 hours) are injected, ventilation is carried out under positive pressure.
It should be noted that overdose of oxygen, a high concentration of glucose solution (40%), drugs of theophylline group are contraindicated in the treatment of status, as having a proconvulsive effect.
As the status is relieved, supportive oral anti-epileptic therapy is immediately restored, which can be started by administering a suspension of crushed tableted preparations through a nasogastric tube, taking into account the previous treatment.
The status of tonic-clonic seizures gives a mortality rate of 3 to 60%. Death arises from disorders of general homeostasis due to irreversible disorders of brain regulatory functions /
The same tactic is used to stop ES complex partial seizures. ES absences successfully stopped by diazepam. With ES myoclonic seizures in patients with myoclonus epilepsy, diazepam often does not cause a lasting effect. In these cases, valproate should be used; in the absence of a soluble form, through a nasogastric tube (up to 80-100 mg / kg) in combination with large doses of nootropil (up to 100 mg / kg / day intravenously). It can be effective and combined no clonazepam with valproate. The dose of clonazepam is from 0.2 to 0.3 mg / kg / day when administered through a nasogastric tube.