Asphyxia with developmental delay and status epileptics

Presented by
M.Kalyan Sai
Pharm D IV year
16T11T0004

Asphyxia :
The condition where the body either does
not get enough oxygen to continue renal function or
has too much carbondioxide to perform its functions
properly is known as asphyxia.
Asphyxia causes generalized hypoxia.

Fetal Hypoxia :
Intrauterine hypoxia occurs when the fetus
is deprived of an adequate supply of oxygen.
 Mother – Hypoventilation during the anesthesia,
respiratory failure or CO poisoning.
 Premature separation of the placenta. PLACENTA
PREVIA.
 Impedance to the circulation of the blood through
the umbilical cord as a result of compression or
knotting of the cord.
 Uterine vessel constriction by coccaine or smoking.

 Extremes in maternal age (< 20 yrs - >35 yrs).
 Preterm or post term gestation.

 Frequency of severe birth asphyxia were higher in
makes than females.
Etiology – High Risk Factors :
 Hypoxia
 Nephritis
 Heart Diseases
 Too older or too young
 Anemia
 Diabetes
 Hypertension
 Smoking

Epidemology :
 Responsible for >8,00,000 neonatal deaths per year
in Africa.
 In contrast to developed countries, initial mortality
of severely asphyxiated babies in low income
countries is high and long term survival after birth
asphyxia is low.
 In Nigeria, birth asphyxia occours in 83.5 per 1000
live births and accounted for 25.9% of total neonatal
death with 58.7% of his death occouring within the
first 24hrs after birth.

Pathophysiology : -
Reduction in oxygen tension
Capillary Dilation
Capillary Stasis
Capillary Enlargement
Stasis of blood in organs

Diminished venous return to heart
Reduced pulmonary flow
Deficient oxygen supply in lungs
ASPHYXIA

Factors :
Decrease in maternal oxygenation
decrease in blood flow from mother to placenta
Blood flow decreases from placenta to fetus
Decrease gas exchange across placenta or fetal tissue
Increase in fetal oxygen required.

Status Epilepticus :
It is a dangerous condition in which epileptics
fits follow one another without recovery of
consciousness between them.
Status epilepticus is when a seizure lasts longer
than 5 minutes or seizures occur close together and the
person doesn’t recover between seizures.
It is a very rare condition.
This includes :-
High Fever
Brain infections
Abnormal sodium levels
Abnormal blood sugar levels
Head injuries
May leads to permanent brain damage or death.

Symptoms :
 Muscle Spasms
 Falling
 Confusion
 Unusual noises
 Loss of bowel or bladder control
 Clenched teeth
 Irregular breathing
 Unusual behavior.

 EPIDEMOLOGY :
a) In children, Status Epilepticus occours within 2
years of the onset of epilepsy.
b) Recurrent status epilepticus is usually associated
with underlying neurological disorder.
c) Status Epilepticus is most common in those <2yrs of
age.
d) 25% of patients with status epilepticus have pre-
existing epilepsy.
e) 4-16% of Patients with epilepsy have atleast 1
episode of SE.

Etiology : -
 Stroke, including haemorrhagic
 Alcohol withdrawn
 Anoxic brain injury
 Metabolic disturbances
 Remote brain injury
 Infections
 Brain neoplasms
 Idiopathic

MANAGEMENT :
Aggressive treatment is necessary for status
epilepticus. Clinicians should not wait for blood level
results before administrating a loading dose of
phenytoin regardless of whether the patient is already
taking phenytoin.
Medications used in treatment of SE :
 Benzodiazepines [e.g. – Lorazepam, diazepam,
midazolam] First Line Drugs.
 Anticonvulsant agents [e.g.- Phenytoin, fosphenytoin]
 Barbiturates [e.g.- Phenobarbital, pentobarbital]
 Anesthetics [e.g.- propofol]

Complications of Status Epilepticus :
I- Hypoxia
II- Acidemia
III- Glucose alterations
IV- Blood pressure disturbances
V- Increased intracranial pressure
VI – Respiratory Failure

 Morbidity
- 10% - 20%
- Neurological Sequelae
- Focal motor deficits
- Mental retardation
- Behavioral disorders
- Chronic epilepsy
- Acute or chronic MRI changes
 Mortality
- 3 – 8%

Pharmacological Treatment :
1. First Line Drugs :
- Lorazepam 2-4mg IV
- Diazepam 5-10mg IV
- Midazolam 2-4mg IV [10mg IM]
2. Second Line Drugs :
- Phenytoin or fosphenytoin 20mg/kg IV
- Valproic acid 20mg/kg IV
- Phenobarbital 20mg/kg IV at 50mg/min
3. Third Line Drugs :
- Pentobarbital 5-15 mg/kg
- Propofol 3-5 mg/kg

A CASE STUDY ON ASPHYXIA WITH
DEVELOPMENTAL DELAY AND STATUS
EPILEPTICUS

SUBJECTIVE
Demographic Details :
A male child patient of age 5
years was admitted in a pediatric ward on 27-4-2019
with the symptoms of seizures.
HPI :
Birth Asphyxia Sensulae with developmental delay
with breakthrough seizures.

SUBJECTIVE
Past Medical History : COMA for a month after
immediate birth.
PAST MEDICATION HISTORY : NIL
Allergies : NIL

OBJECTIVE
PARAMETER VALUE
Pulse Rate 120bpm
Respiratory Rate 24/min
CVS S1 S2 +
CNS Developmental Delay
Respiratory System clear
P/A Soft

LAB INVESTIGATIONS
CT Scan :- Normal
CNS :- Drowsy 1 arousal
Meningial irritation – NO
Neck Stiffness – NO
Glasgow coma Scale – E2 V5 M2
Total Score = 09
ASSESSMENT :
ASPHYXIA WITH DEVELOPMENTAL DELAY AND
STATUS EPILEPTICUS

DRUGS PRESCRIBED ON ADMISSION
Day – 1
1. O2 inhalation
2. Inj.Midazolam 1.3cc IV stat given & sos
3. Inj.Phenytoin loading dose 260mg IV stat
4. Inj.Ceftriaxone 600mg IV BD
5. IVF DNS 350ml 8th hourly
6. Anamol 180ml sos

Da
y
On examination Pt
complaints
Drug Dose Frequency
2 Vitals stable
CVS – S1 S2 +
RS – BAE+
CNS – NAD
P/A - Soft
No further
seizures
Fever
CST
+
T.Paraceta
mol
500mg
(1/2)
IV BD
TID
SOS
3 Vitals Stable
CVS – NAD
CNS – NAD
RS – NAD
P/A - Soft
No further
seizures
Fever
CST
+
IVF DNS
350ml IV BD
TID
SOS
4 Febrile
CVS – NAD
CNS – NAD
RS – NAD
P/A - Soft
Fever CST
+
Inj.Amikaci
n
200mg IV OD

Da
y
On Examination Pt
Complaint
s
Drug Dose Frequency
5 AFebrile
PR – 120/min
RR – 24/min
CVS – S1S2 +
CNS –
Developmental
Delay
RS – Clear
P/A - Soft
No further
seizures
Fever
Decreased
CST
Stop IVF
SOS
6 &
7
Afebrile
Vitals – Stable
CVS – NAD
RS – NAD
CNS – Conscious
& oriented
P/A - Soft
No Furthur
Seizures
Inj.Ceftriax
one
Inj.Phenyto
in
T. PCT
T. B
Complex
Inj.Amikaci
n
650mg
35mg
½
200mg
IV BD
IV BD
TID
OD
IV OD

MY PLAN
 If seizures continue after 20 mins, give additional
fosphenytoin[10mg/kg IV] or Phenytoin[10mg/kg
IV]. Aim for a total serum phenytoin levels of about
22-25 micrograms/ml.
 Benzodiazepines [e.g. – Lorazepam, diazepam,
midazolam] First Line Drugs.
 Anticonvulsant agents [e.g.- Phenytoin,
fosphenytoin] Second line drugs
 Barbiturates [e.g.- Phenobarbital, pentobarbital]
Third line drugs
 Anesthetics [e.g.- propofol]

INTERVENTIONS :
 Phenytoin + Midazolam = Phenytoin will decrease
the effect of midazolam by affecting
hepatic/intestinal enzymes metabolism.
 Phenytoin or Midazolam + Amikacin = Phenytoin
or Midazolam will decrease the effect of amikacin
by P-glycoprotein efflux transporter.

 SUBJECTIVE :
Past Medical History : COMA for a month after
immediate birth.
PAST MEDICATION HISTORY : NIL
Allergies : NIL
OBJECTIVES :
CT Scan :- Normal
CNS :- Drowsy 1 arousal
Meningial irritation – NO
Neck Stiffness – NO
Glasgow coma Scale – E2 V5 M2
Total Score = 09

 ASSESSMENT :
ASPHYXIA WITH DEVELOPMENTAL DELAY
AND STATUS EPILEPTICUS
RESOLUTION :
 Phenytoin + Midazolam = Phenytoin will decrease
the effect of midazolam by affecting hepatic/intestinal
enzymes metabolism.
 Phenytoin or Midazolam + Amikacin = Phenytoin or
Midazolam will decrease the effect of amikacin by P-
glycoprotein efflux transporter.

 MONITORING :
Phenytoin decreases the effect of midazolam by
affecting the metabolism of intestine enzymes.
Phenytoin or Midazolam will decrease the
effect of amikacin by P-glycoprotein efflux
transporter.
We can control this by regulating the doses
between the drugs.

 Adverse Effects
Midazolam :
 Drowsiness
 Apnea
 Nausea / vomiting
 Seizure like activity
 Pain at injection site
Amikacin :
 Hypotension
 Headache
 Rash
 Nausea / Vomiting

Phenytoin :
 Drowsiness
 Fatigue
 Headache
 Restlessness
 Slurred speech
 Nervousness
Ceftriaxone :
 Diarrhea
 Rash
 Leukopenia
 Thrombocytosis

Non Pharmacological Treatment :
 Should not withdrawn epileptic drugs.
 If any antibiotic given should use total course
 Should maintain a healthy diet
 Contact your health care provider if any seizures
are noticed.
 Ketogenic diet[Chicken, Ginger, onion, tomato,
garlic] should be maintained.
 By following ketogenic diet we can control seizures
nearly upto 50 – 80%.

Asphyxia with developmental delay and status epileptics

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