+

SEIZURE
dr. RETNO JAYANTRI KETAREN, SpS
BLOK NEUROBEHAVIOUR
BANGKITAN / KEJANG
Kompetensi Dokter Umum (SKDI, 2012)

3A. Epilepsi 3B Status Epileptikus

1. Mampu membuat diagnosis

1. Mampu membuat diagnosis klinik dan memberikan terapi
klinis pendahuluan pada keadaan
2. Mampu melakukan terapi gawat darurat à
pendahuluan menyelamatkan nyawa,
3. Mampu merujuk ke dr. mencegah keparahan
Spesialis Saraf dan/atau kecacatan
4. Mampu menerima rujukan 2. Mampu menentukan rujukan
balik setelah dikonsulkan ke yang paling tepat bagi
dr. Spesialis saraf penanganan pasien
selanjutnya
3. Mampu menindaklanjuti
sesudah kembali dari rujukan
KEJANG

STATUS
EPILEPTIKUS

EPILEPSI
 Bangkitan / Kejang

Kejang/Bangkitan epileptik :
Terjadinya tanda / gejala yang
bersifat sesaat akibat aktifitas
neuronal yang abnormal dan
berlebihan di otak

Engel J, Pedley TA.Chapter 1. Epilepsy: a comprehensive textbook. 2nd edition. Philadelphia: Lippincott
Williams & Wilkins, 2008
+
EPILEPSY

ILAE (INTERNATIONAL LEAGUE AGAINST EPILEPSY) 2017

OPERATIONAL DEFINTION OF EPILEPSY :

1. At least two unprovoked (or reflex) seizures occuring

> 24 hrs apart
2. One unprovoked (or reflex) seizure and a probability
of further seizures similar to the general recurrence
risk (at least 60%) after two unprovoked seizures,
occuring over the next 10 years
3. Diagnosis of an epilepsy syndrome
+
STATUS EPILEPTICUS

ILAE (INTERNATIONAL LEAGUE AGAINST EPILEPSY)

GENERALIZED CONVULSIVE STATUS

EPILEPTICUS :

Ø5 minutes of continuous seizure or

Ø Two or more discrete seizures between which

there is incomplete recovery of consciousness
/
 ANAMNESIS BANGKITAN
²PRE-IKTAL : aura, aktivitas yang sedang
dilakukan pasien (tidur, saat bermain
video game, sedang dalam lampu
berkedep-kedip)
²IKTAL : deviasi mata, gerakan kepala, kaku,
kelojotan, Apakah terdapat lebih dari 1
pola bangkitan, apakah ada perubahan
pola dari bangkitan sebelumnya.
² POST-IKTAL : bingung, langsung sadar,
nyeri kepala, Todd’s paresis
+

BANGKITAN ?
 ACUTE SYMPTOMATIC SEIZURE

A diagnosis of acute symptomatic seizure

should be made in the presence of severe
metabolic derangements (documented
within 24 h by specific biochemical or
hematologic abnormalities), drug or alcohol
intoxication and withdrawal.

Commission on Terminology 2010

+ TATALAKSANA KEJANG
 REAL ?

NOT
REAL ?

+
+ TATALAKSANA EPILEPSI

Level of confidence :
A: efektif sebagai monoterapi ; B sangat mungkin efektif sebagai monoterapi ;
C mungkin efektif sebagai monoterapi ; D berpotensi untuk efektif sebagai
monoterapi
+ TATALAKSANA EPILEPSI

START LOW
GO SLOW
+ TATALAKSANA EPILEPSI
CARBAMAZEPINE
+

DOSIS :

10 – 20 mg/kgBB

Hepatic enzyme inducer

MECHANISM
+ OF ACTION

Inactivation of the Na channels

Inhibits NMDA receptor

SIDE
+ EFFECTS

n Sindroma Steven-Johnson,

n Lupus-like syndrome

n Anemi aplastik, hepatotoksisitas,

n Dizziness, ataksia, diplopia, mual, kelelahan, agranulositosis,lekopeni,

tromositopenia, hiponatremia, ruam, gangguan perilaku,
tiks,peningkatan berat badan, disfungsi seksual, disfungsi hormon
tiroid, nuropati perifer

Pedoman Tatalaksana Epilepsi 2014

PHENYTOIN
+

DOSIS :
5 -8 mg/kgBB

Hepatic enzyme inducer

MECHANISM
+ OF ACTION

Inactivation of the Na channels

Inhibition of Ca channels
SIDE
+ EFFECTS

n Sindrom Steven-Johnson

n Anemia aplastik

n Gangguan fungsi hati

n Hipertrofi gusi

n Hirsurtisme, ataksia, nistagmus, diplopia, ruam, anoreksia,

mual, macroxytosis, neuropati perifer, agranulositosis,
trombositopenia, disfungsi seksual, disfungsi serebellar,
penurunan absorpsi calcium pada usus

Pedoman Tatalaksana Epilepsi

PHENOBARBITAL
+

DOSIS :
2 - 4 mg/kgBB

Hepatic enzyme inducer

MECHANISM
+ OF ACTION

Enhances GABA (GABA-ergic potentiation)

SIDE
+ EFFECTS

n Hepatotoksik

n Gangguan jaringan ikat dan sumsum tulang

n Sindrom Steven-Johnson

n Mengantuk, ataksia, nistagmus, ruam kulit, depresi, hiperaktif

(pada anak), gangguan belajar (pada anak), disfungsi
seksual

Pedoman Tatalaksana Epilepsi

VALPROIC
+ ACID

DOSIS :
15-40
mg/kgBB

Hepatic enzyme inhibitor

MECHANISM
+ OF ACTION

Multifactorial mechanisms : enhances GABA,

inhibits Glutamate, Ca channel inductor

SIDE
+ EFFECTS

n Hepatotoksisitas,

n Hiperamonemia

n Leukopenia, trombositipenia

n Pankreatitis

n Mual, muntah, rambut menipis, tremor, amenore, peningkatan

berat badan, konstipasi, hirsustisme, alopesia pada
perempuan, POS (Polycistic Ovarii Syndrome)

Pedoman Tatalaksana Epilepsi

AED
+ INTERACTIONS

ORAL •Become less effective

CONTRACEPTI • Decrease in Lamotrigine serum
levels
ONS
ANTIBIOTICS • Macrolide (Erythromycine), INH à
increase AEDS serum level
• Rifampycine à decrease AEDS serum
level
• Increase elimination of Tetracycline
ANTI RETRO • Decrease ARV serum level
VIRAL

ANTI • Cyclophosphamide, MTX à become

NEOPLASTIC less effective
Epilepsy Essentials • Tamoxifen à increase AEDS serum
SEIZURE ?
+ TATALAKSANA STATUS EPILEPTIKUS
+
Obat Oral untuk Status Epilepticus

Levetiracetam Pregablain Topiramate

Paling sering
digunakan Dosis : 342 – 360 Loading dose :
mg 400 mg
melalui NGT

USA : baru disetujui

Dosis : 2000- 3000 sebagai terapi ajuvan Maintain dose :
pada pasien dengan
mg/ hari bangkitan parsial yang 100 mg/hari
refrakter

Anak-anak : dosis
inisial à 20
mg/kg/hari, dosis
mingguan
ditingkatkan hingga 10
mg/kg/hari.

Zheng F et al. Levetiracetam for the treatment of status epilepticus. Expert Rev. Neurother. 15(10), 1113–1121 (2015)
Swisher C et al. Use of pregabalin for nonconvulsive seizures and nonconvulsive status epilepticus. Seizure 22 (2013) 116–118
Suttichaimongkol T, et al. The efficacy of topiramate in status epilepticus, experience from Thailand. Neurology Asia 2012; 17(4) : 297 – 302
+

SEIZURE
?
 REAL ?

NOT REAL ?

+
 SEIZURE ?

+
BANGKITAN ?
T
H
A
N
K

YOU
FOCAL ONSET AWARE MOTORIC
FOCAL ONSET IMPAIRED AWARENESS MOTORIC
GENERALIZED ONSET MOTORIC : MYOCLONIC
GENERALIZED ONSET NON-MOTORIC : ABSANCE
FOCAL ONSET TO BILATERAL TONIC CLONIC
GENERALIZED ONSET : ATONIC
GENERALIZED ONSET : TONIC CLONIC
 SPECIAL CASES

• Children usually have faster drug elimination

rates and reduced serum half-lives relative to
adults.
• In the elderly, AEDs should usually be started
at a lower dose and increased at a slower rate
than in younger patients. Elimination of many
drugs is slower in the elderly, mainly because
of reduced hepatic and renal blood flow

Journal of the Malta College of Pharmacy Practice 2005

 SPECIAL CASES

• Pregnancy increases the volume of distribution

and the rate of drug metabolism, and
decreases protein binding. For most AEDs, the
optimal dose increases as pregnancy
progresses

Journal of the Malta College of Pharmacy Practice 2005

BANGKITAN
?
BANGKITAN ?
BANGKITAN ?
BANGKITAN ?
AEDS PHARMACOKINETICS
 STEADY STATE

5 X HALF LIFE

CBZ 0 – 0 – 1/2

CBZ 0 – 0 – 1

CBZ 1/2 – 0 – 1

CBZ 1 – 0 – 1
AEDS PHARMACOKINETICS
PHARMACOKINETICS
AEDS PHARMACOKINETICS
AEDS PHARMACOKINETICS
 INTERACTIONS WITH NEW AEDS
OAE Tabel 6.Interaksi Farmokinetik antar-obat anti epilepsi (OAE) 18
TAMBAHAN OAE YANG TERKENA DAMPAK INTERAKSI

CBZ CLB CZP ESM GBP LAM LE OXC PB PHT PRM TPM VPA VGB TGB ZNS
V

CARBAMAZEPIN AI ¯CLB ¯CZP ¯ ESM O ¯LAM O O O ­­/¯¯ ¯PRM ¯ TPM ¯¯VPA O ¯TGB ¯ZNS
CLOBAZAM ¯CB - O O O O O O ­PB PHT ¯PRM O ­VPA O O O
CLONAZEPAM Z O - O O O O O O ­/¯PHT O O O O O O
GABAPENTIN O O O O - O O O O ­/¯PHT O O ¯¯ O O O
LAMOTRIGINE O O O O O - O O O ­PHT O ? O O O O
LEVETIRACETA O O O O O O - O O O O O O O O O
M O O O O O ¯LAM O - O O O O O O O O
OXCARBAZEPIN O ¯CBZ ¯CZP ¯ESM O ¯¯LAM O ­ - O NCP ¯¯TPM O O ¯TGB ¯ZNS
E AI ¯CBZ ¯CZP ¯ESM O ¯¯LAM O OXC ­­PB ­­/¯¯ ­/¯ ¯¯TPM ¯¯ O ¯TGB ¯ZNS
PHENOBARBITA ¯CB ¯CBZ ¯CZP ¯ESM O ¯¯LAM O O NCP PHT PRM ¯¯TPM VPA O O O
L Z O O O O O O O O - - - ¯¯ O O O
PHENYTOIN ¯CB O O ­/¯ O ­/¯ O O ­­PB ­­/¯¯ O ¯TPM VPA O O O
PRIMIDONE Z ESM LAM O PHT ­PRM ¯¯
TOPIRAMATE O ­­PHT VPA
VALPROATE ­­ ­­/¯¯ ¯¯
CBZ PHT VPA
E -