てんかん重積 — 管理パス

パス全体像

1. 【判断】Recognize & initial stabilization (0–5 min)
   Does it meet SE criteria and is initial stabilization done?（Convulsive SE = lasting ≥5 min, or consciousness not recovered between two seizures. Initial stabilization: ABC, oxygen, monitoring, IV access, check glucose (low → 50% dextrose + thiamine), check electrolytes/calcium/magnesium/toxicology/antiseizure-drug levels, find the trigger.）
   • Meets it → first-line drug → First-line · benzodiazepine (5–20 min)
   • <5 min or self-terminated → SE not met → observe
2. 【終点】SE not met → observe
   初期：気道・酸素・血糖。ベンゾジアゼピン（ Lorazepam静注/ Midazolam筋注など施設プロトコル）。5–10分で持続なら二次薬（レベチラセタム、バルプロ酸、ホスフェニトイン等）。難治は麻酔薬とICU。
3. 【判断】First-line · benzodiazepine (5–20 min)
   Did seizures stop after an adequate first-line benzodiazepine?（Adequate single dose: IV lorazepam 0.1 mg/kg (max 4 mg per dose, may repeat once); if no IV access, IM midazolam 10 mg (>40 kg) / 5 mg (13–40 kg); or IV diazepam 0.15–0.2 mg/kg (max 10 mg). Underdosing is the most common cause of failure.）
   • Stopped → Seizures stopped · maintenance
   • Not stopped → second-line → Second-line · antiseizure drug (20–40 min)
4. 【判断】Second-line · antiseizure drug (20–40 min)
   Did seizures stop after a second-line antiseizure drug?（Choose one adequate IV dose: levetiracetam 60 mg/kg (max 4500 mg), valproate 40 mg/kg (max 3000 mg), or fosphenytoin 20 mg PE/kg (max 1500 mg). The ESETT trial showed all three are equally effective.）
   • Stopped → Seizures stopped · maintenance
   • Not stopped → refractory → Refractory SE (40–60 min)
5. 【終点】Refractory SE (40–60 min)
   難治SE（適切な二系統薬失敗）：挿管＋持続脳波監視下麻酔—ミダゾラム/プロポフォール/ペンobarbital等の持続静注。
6. 【終点】Seizures stopped · maintenance
   痙攣停止後：再発予防の抗痙攣薬を維持。持続監視し非痙攣性SEに注意。原因治療。