硬膜下血肿术后癫痫持续状态-简单学案.ppt

* Diazepam and lorazepam (valium – ativan) are equally effective Midazolam (Versed) – never compared in a study Fosphenytoin (150mg/min infusion rate) is quicker and less side effects (phlebits, purple glove phenomenon) than phenytoin (50mg/min infusion rate) Evidence supporting valproic acid is lacking, but anectodal reports suggest it is effective Propofol, barbs, and midazolam drip all appear to be equally succefull, however midazolam probably better in individuals who have not received sufficient benzos Ketamine: “agent of last resort”, has proved useful in refractory status epilepticus,154 is neuroprotective,155 and is effective in drug-resistant experimental status epilepticus.57,156 However, because ketamine can raise intracranial pressure, the absence of intracranial masses should be confirmed (by CT scan, for example) before using it. We consider its NMDA antagonist properties as an asset, despite expressed concerns,157 but limited experience restricts its use to refractory cases. 154 Sheth RD, Gidal BE. Refractory status epilepticus: response to ketamine. Neurology 1998; 51: 1765–66. 155 Fujikawa DG. Neuroprotective effect of ketamine administered after status epilepticus onset. Epilepsia 1995; 36: 186–95. 156 Borris DJ, Bertram EH, Kapur J. Ketamine controls prolonged status epilepticus. Epilepsy Res 2000; 42: 117–22. 157 Ubogu EE, Sagar SM, Lerner AJ, Maddux BN, Suarez JI, Werz MA. Ketamine for refractory status epilepticus: a case of possible ketamine-induced neurotoxicity. Epilepsy Behav 2003; 4: 70–75. * 亚急性、慢性硬膜下血肿术后癫痫持续状态 首都医科大学宣武医院 神经外科重症监护病房 徐跃峤 2014-3-25 病 例 男 ，64岁。主因头部撞伤后14天, 言语不清13小时入院。 14天前坐车途中撞伤头部,伤后头痛头晕, 次日外院CT示左侧额颞顶硬膜下血肿,对证治疗.入院前2日行引流术,术后出现右侧上肢无力,言语不清，意识障碍,嗜睡。 入院查体：不全混合性失语， 右侧上肢3级，下肢4级。 左侧肌力正常。 CT检查 MRI MRI 入院次日，出现右侧面部及右侧肢体抽搐，以面部为主，牙关紧闭，双眼像右侧凝视，意识不清。 肢体抽动上肢重，下肢轻。 持续约1.5min，安定10毫克静推后缓解，神智恢复，但右侧肢体肌力下降为2级。 需要口咽通气道 丙戊酸钠泵入，24小时后逐渐减量改为口服。 36小时后，癫痫大发作。 四肢抽搐伴肌张力增高。心率、血压升高、 予以安定 10mg、10mg、20mg静推，鲁米那肌肉注射。发作