The recommendations in this 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) after the publication of the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 1,2 and was completed in February 2015.3,4

In this in-depth evidence review process, ILCOR examined topics and then generated a prioritized list of questions for systematic review. Questions were first formulated in PICO (population, intervention, comparator, outcome) format,5 and then search strategies and inclusion and exclusion criteria were defined and a search for relevant articles was performed. The evidence was evaluated by the ILCOR task forces by using the standardized methodological approach proposed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group.6

The quality of the evidence was categorized based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and other considerations (including publication bias). Then, where possible, consensus-based treatment recommendations were created.

To create this 2015 Guidelines Update, the AHA formed 15 writing groups, with careful attention to manage conflicts of interest, to assess the ILCOR treatment recommendations and to write AHA treatment recommendations by using the AHA Class of Recommendation (COR) and Level of Evidence (LOE) system. The recommendations made in the Guidelines are informed by the ILCOR recommendations and GRADE classification, in the context of the delivery of medical care in North America. The AHA writing group made new recommendations only on topics specifically reviewed by ILCOR in 2015. This chapter delineates instances where the AHA writing group developed recommendations that are significantly stronger or weaker than the ILCOR statements. In the online …

Part 8: Post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care

The Commission on Classification and Terminology and the Commission on Epidemiology of the International League Against Epilepsy (ILAE) have charged a Task Force to revise concepts, definition, and classification of status epilepticus (SE). The proposed new definition of SE is as follows: Status epilepticus is a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms, which lead to abnormally, prolonged seizures (after time point t1 ). It is a condition, which can have long-term consequences (after time point t2 ), including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures. This definition is conceptual, with two operational dimensions: the first is the length of the seizure and the time point (t1 ) beyond which the seizure should be regarded as "continuous seizure activity." The second time point (t2 ) is the time of ongoing seizure activity after which there is a risk of long-term consequences. In the case of convulsive (tonic-clonic) SE, both time points (t1 at 5 min and t2 at 30 min) are based on animal experiments and clinical research. This evidence is incomplete, and there is furthermore considerable variation, so these time points should be considered as the best estimates currently available. Data are not yet available for other forms of SE, but as knowledge and understanding increase, time points can be defined for specific forms of SE based on scientific evidence and incorporated into the definition, without changing the underlying concepts. A new diagnostic classification system of SE is proposed, which will provide a framework for clinical diagnosis, investigation, and therapeutic approaches for each patient. There are four axes: (1) semiology; (2) etiology; (3) electroencephalography (EEG) correlates; and (4) age. Axis 1 (semiology) lists different forms of SE divided into those with prominent motor systems, those without prominent motor systems, and currently indeterminate conditions (such as acute confusional states with epileptiform EEG patterns). Axis 2 (etiology) is divided into subcategories of known and unknown causes. Axis 3 (EEG correlates) adopts the latest recommendations by consensus panels to use the following descriptors for the EEG: name of pattern, morphology, location, time-related features, modulation, and effect of intervention. Finally, axis 4 divides age groups into neonatal, infancy, childhood, adolescent and adulthood, and elderly.

https://onlinelibrary.wiley.com/doi/epdf/10.1111/epi.13121

A Definition and Classification of Status epilepticus--Report of the ILAE Task Force on Classification of Status Epilepticus

The International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support (ALS) Task Force performed detailed systematic reviews based on the recommendations of the Institute of Medicine of the National Academies1 and using the methodological approach proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group.2 Questions to be addressed (using the PICO [population, intervention, comparator, outcome] format)3 were prioritized by ALS Task Force members (by voting). Prioritization criteria included awareness of significant new data and new controversies or questions about practice. Questions about topics no longer relevant to contemporary practice or where little new research has occurred were given lower priority. The ALS Task Force prioritized 42 PICO questions for review. With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library).

By using detailed inclusion and exclusion criteria, articles were screened for further evaluation. The reviewers for each question created a reconciled risk of bias assessment for each of the included studies, using state-of-the-art tools: Cochrane for randomized controlled trials (RCTs),4 Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 for studies of diagnostic accuracy,5 and GRADE for observational studies that inform both therapy and prognosis questions.6

GRADE evidence profile tables7 were then created to facilitate an evaluation of the evidence in support of each of the critical and important outcomes. The quality of the evidence (or confidence in the estimate of the effect) was categorized as high, moderate, low, or very low,8 based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and other considerations (including publication bias).9

These evidence profile tables were then used to create a …

/pdf/part-4-advanced-life-support-2015-international-consensus-on-3s0zzf6w8u.pdf

Part 4: Advanced life support: 2015 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations

European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015.

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.

/pdf/european-resuscitation-council-and-european-society-of-3dwqws4emi.pdf

European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care.

Continuous EEG Monitoring is becoming a commonly used tool in assessing brain function in critically ill patients. However, there is no uniformly accepted nomenclature for EEG patterns frequently encountered in these patients such as periodic discharges, fluctuating rhythmic patterns, and combinatio

American Clinical Neurophysiology Society's Standardized Critical Care EEG Terminology: 2012 version.

Summary


Purpose: To compare pharmacokinetics, tolerability, and efficacy of lamotrigine (LTG) in older versus younger adults.



Methods:  We studied 686 adult outpatients seen at our center over 5 years. We compared apparent clearance (CL) of LTG in the youngest (16–36 years; n = 247) and oldest (55–92 years; n = 155) tertiles. We analyzed one-year retention for younger and older adults newly started on LTG, frequency of adverse effects causing intolerability, and rates of specific adverse effects. We also investigated 6-month seizure freedom.



Key Findings:  Median LTG CL of older adults taking LTG in monotherapy was approximately 22% lower compared to younger adults (28.8 vs. 36.5 ml/h/kg; p  15 μg/ml).



Significance:  LTG CL in monotherapy in older adults is approximately 20% lower than in younger adults. For a given serum LTG level, older adults are twice as likely to have significant adverse effects compared to younger adults. Older patients are more likely to experience imbalance, drowsiness, and tremor than younger patients. Younger adults tolerate LTG better than older adults, but one-year retention is comparable. Some patients may benefit from high serum levels of LTG.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1528-1167.2011.03217.x

The effect of age and comedication on lamotrigine clearance, tolerability, and efficacy.

New-onset refractory status epilepticus (NORSE) describes a prolonged seizure state of unknown etiology that occurs in a person without prior seizures.1 The prognosis in the literature is poor.1,–,4 We present a patient with NORSE who recovered after 4 months of coma.

### Case report.

A healthy 29-year-old man with no epilepsy risk factors experienced 2 weeks of upper respiratory symptoms followed by lethargy. On admission to a regional hospital he was stuporous, febrile, and vomiting. The following day, he experienced multiple generalized convulsions requiring intubation. Ten days later, he was transferred to Columbia on continuous IV propofol and midazolam, as well as levetiracetam, phenytoin, and phenobarbital.

Continuous EEG (cEEG) showed electrographic status epilepticus (figure e-1 on the Neurology ® Web site at www.neurology.org). Upon admission, he was comatose, with absent cranial nerve reflexes except for sluggishly reactive pupils. All autoimmune, paraneoplastic, and infectious laboratory studies were negative except for antinuclear antibody. Brain biopsy showed nonspecific inflammation; however, the etiology was never identified. See table e-1 for diagnostic tests and figure e-2 for select MRIs.

His seizures were highly refractory, requiring high doses of IV midazolam, pentobarbital, and ketamine; treatments administered are listed in table e-2. He …

Recovery after severe refractory status epilepticus and 4 months of coma

A man in his 30s with encephalocraniocutaneous lipomatosis (ECCL), hydrocephalus, ventriculoperitoneal shunt, and Lennox-Gastaut syndrome was seen for epilepsy. He had multiple facial subcutaneous nodules (lipomas), near-blindness bilaterally, and right spastic hemiparesis. He was fluent, dysarthric, and followed one-step commands. A partially thrombosed internal carotid aneurysm was found on imaging (not shown).

ECCL is a neurocutaneous syndrome resulting from ectomesodermal dysgenesis, …

https://n.neurology.org/content/neurology/77/7/694.full.pdf

Alexandra Svoronos

Papers

American Clinical Neurophysiology Society's Standardized Critical Care EEG Terminology: 2012 version.

The effect of age and comedication on lamotrigine clearance, tolerability, and efficacy.

Recovery after severe refractory status epilepticus and 4 months of coma

Imaging findings in encephalocraniocutaneous lipomatosis