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Penatalaksanaan Kejang Pada Covid19: Suryo Bantolo Rs Dcwak
Penatalaksanaan Kejang Pada Covid19: Suryo Bantolo Rs Dcwak
Penatalaksanaan Kejang Pada Covid19: Suryo Bantolo Rs Dcwak
pada Covid19
Suryo Bantolo
RS DCWAK
Contoh kasus
A 72 year old man with history of hypertension, coronary artery disease with
stent, diabetes type 2, end stage kidney disease on hemodialysis presented
with complaints of weakness and lightheadedness after experiencing a
hypoglycemic episode. Initially admitted to the medical floor the patient
shortly developed worsening respiratory status with increased work of
breathing and altered mental status requiring intubation and transfer to the
intensive care unit. Initial ABG showed a pH of 7.13, PaO2 of 68 mmHg and
PCO2 of 78 mmHg. BNP was elevated at 541 pg/mL. Troponin was elevated
at 0.11 ng/mL and peaked at 0.35 ng/mL. Suspicion for COVID 19 was
raised after finding abnormal labs typically seen in COVID 19 patients [1]:
elevated CRP at 61 mg/L, LDH of 230 U/L, lymphopenia noticed at 0.5
k/cmm with leukopenia at 4000k/cmm. A chest x-ray on admission was
negative. Patient was started on oseltamivir however was discontinued
when Influenza tested negative Two sets of blood cultures were negative
for bacterial growth.
The patient became hypotensive requiring norepinephrine via central line.
A real time PCR for SARS COV-2 was positive. Hydroxychloroquine and
azithromycin was started in addition to antimicrobials of vancomycin and
piperacillin tazobactam. CT head showed chronic microvascular ischemic
changes but did not show any acute changes infarct or hemorrhage. CT
chest showed bibasilar opacities along with right lower lobe consolidation.
On day 3 of admission, patient was noted to have multiple episodes of
tonic colonic movements of his upper and lower extremities that lasted for
many minutes before abating with versed 4 mg IV push. Versed drip was
started. A loading dose of levetiracetam was given followed by
maintenance dose dosed renally. 24 h EEG showed six left temporal
seizures and left temporal sharp waves which were epileptogenic. For the
next 2 days patient was observed having tonic movements of his upper
extremities 2-3 times daily. Valproate was added to the antiseizure regimen.
On hospital day 5 of admission a code blue was called after patient
became pulseless. Unfortunately, ROSC could not be achieved and the
patient passed.
OUTLINE
Definisi Convulsive seizure
Patofisiologi seizure
Etiologi convulsive seizure
Differential diagnosis
Penyakit sistemik sebagai faktor risiko seizure
Manifestasi saraf pusat pda Covid19
Convulsive seizure pada Covid19
Penatalaksanaan convulsive seizure
Mekanisme aksi OAE
First Line ASM
Second Line ASM
Status epileptikus
Definisi convulsive seizure
Manifestasi klinis dari aktivitas listrik abnormal dari otak spontan yang
yang tampak dalam bentuk gerakan otot yang cepat dan ritmik,
kontraksi dan relaksasi yang bergantian
Patofisiologi seizure
Bangkitan dimulai dengan eksitasi dari neuron serebral yang rentan, yang
berlanjut menjadi letupan yang sinkron dari neuron terkoneksi
(Connectome) yang lebih luas secara progresif
Neurotransmitter yang terlibat adalah Glutamate yang merupakan
neurotransmitter eksitatori utama, dan gamma-aminobutyric acid (GABA)
yang merupakan neurotransmitter inhibitori terpenting
Ketidakseimbangan dari eksitasi berlebihdan dan penurunan inhibisi
menginisiasi aktivitas elektrikal abnormal.
Etiologi convulsive seizure
Electrolyte imbalance (Hiponatremia, Hipernatremia, hipoglikemia,
hipokalsemia)
Withdrawal syndrome (Etanol, benzodiazepine)
Irreguleritas dalam pemakaian obat antiepilepsi/incompliance
Sepsis
Infeksi Sistem saraf pusat
Hypoxic brain injury
Traumatic brain injury
Stroke
Neoplasma
Inflamasi
Demam
Sleep deprivation
Differential diagnosis
Syncope
Psychogenic nonepileptic seizures
Movement disorders
Sleep-related movements
Penyakit sistemik sebagai faktor risiko
kejang
Gangguan renal
Hiperbilirubinemia
Critical ill (Sepsis, DIC)
Penyakit Otoimun (SLE, APS)
Anoxic-Hypoxic
Manifestasi saraf pusat pada Covid19
febrile seizures
Convulsions
loss of consciousness
Encephalomyelitis
Encephalitis
Convulsive seizure pada Covid19
Jaga ABC
Jaga CBF
Koreksi etiologi
Obat anti kejang
Manitolisasi
Mekanisme aksi OAE
Stadium Penatalaksanaan
Stadium 1 (0-10 menit) ABC
Stadium 2 (1-60 menit) • Pemeriksaan status neurologis
• Pengukuran TTV
• Monitor status metabolik,AGD,Hematologik
• EKG
• Pasang IV Line dengan NaCl 0,9%
• Ambil 5-10 cc darah untuk pemeriksaan lab
• Berikan OAE emergensi : Diazepam 0,2 mg/kg dengan kecepatan
pemberian 5 mg/menit iv, dapat diulang bila masih kejang dalam
5 mnt
• Masukkan 50 cc glukosa 50% bila hipoglikemi
• Thiamin 250 mg iv pada alkoholisme
• Menangani asidosis dengan bikarbonat
Stadium 3 (0-60/90 menit) • Menentukan etiologi
• Bila masih kejang, berikan phenytoin iv 15-20 mg/kg
dengan kecepatan ≤ 50 mg/menit (monitor tekanan
darah dan EKG)
• Bila masih kejang beri phenytoin tambahan 5-10
mg/kg
• Bila masih kejang, berikan phenobarbital 20 mg/kg
dengan kecepatan 50-75 mg/kg (Monitor respirasi),
dapat diulang 5-10 mg/kg
• Mulai terapi vasopressor (dopamine) bila perlu
• Koreksi komplikasi
Stadium 4 (30-90 menit) • Bila tidak teratasi dalam 30-60 menit, pindahkan ke
ICU, beri profopol 2mg/kg bolus iv atau midazolam 0,1
mg/kg dengan kecepatan pemberian 4 mg/menit),
atau tiopenton 100-250 mg bolus iv pemberian dalam
20 menit dilanjutkan bolus 50 mg setiap 2-3 menit,
dilanjutkan selama bangkitan klinis atau bangkitan
EEG berakhir, lalu tapering off
• Monitor bangkitan, EEG, tekanan intracranial, mulai
OAE dosis rumatan
Contoh sediaan OAE injeksi