Status epilepticus resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]; Rim Halaby, M.D. [3]

Definition

Status epilepticus is defined as continuous clinical and/or electroencephalographic seizure persisting longer than 5 minutes or the occurrence of two or more episodes of seizures within one hour without returning to the baseline level of consciousness between the seizures.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Status epilepticus is a life threatening condition by itself because it results in serious immediate and long term morbidity and mortality if the convulsive seize is not terminated by 30 minutes; therefore, treatment is required urgently.

Common Causes

• Brain abscess
• Brain trauma
• Cardiac arrest
• Cerebrovascular disorders
• CNS tumor
• Drug toxicity
• Electrolytes abnormalities
• Encephalitis
• Hypertensive encephalopathy
• Hypoglycemia
• Hypoxia
• Low antiepileptic drug levels in patients with epilepsy
• Meningitis
• Sepsis
• Stroke
• Uremia
• Withdrawal from opioids, benzodiazepine, barbiturates or alcohol
• Alcoholism

Management

Shown below is an algorithm summarizing the approach to status epilepticus. The goal of the treatment is to stop the seizure as soon as possible; therefore, begin the general measures and administer the antiepileptic medications (AED) SIMULTANEOUSLY.

Characterize the symptoms: ❑ Aura (altered vision and/or hearing), AND/OR ❑ Tonic phase with muscle spasms, AND/OR ❑ Rapid jerky movement, AND/OR ❑ Uprolling of eyes, AND/OR ❑ Tongue bite, AND/OR ❑ Incontinence

General measures to be done SIMULTANEOUSLY and in PARALLEL to the administration of antiepileptic medications (Emergency): Begin initial care: ❑ Turn patient to side ❑ Secure airway ❑ Assess respiratory and cardiac functions ❑ Administer high concentration O2 ❑ Establish IV access ❑ Institute regular monitoring for pulse, blood pressure, temperature ❑ ECG monitoring ❑ Check fingerstick glucose, and correct hypoglycemia if present (Emergency) Order labs: ❑ Full blood count ❑ Plasma electrolytes ❑ Blood gases ❑ Glucose ❑ Renal and liver function ❑ Serum calcium and magnesium ❑ Blood clotting ❑ Drug levels (if patient is on AED) ❑ Obtain 5 ml of serum and 50 ml of urine sample for toxicology screen Consider vitamin deficiencies: ❑ Administer glucose (50 ml of 50% solution) and/or IV thiamine (250 mg) if suspected alcohol abuse or impaired nutrition ❑ Supplement IV pyridoxine if suspected pyridoxine deficiency Consider alternative diagnosis: ❑ Psychogenic non-epileptic seizures Treat acidosis if severe

Administer AED (Emergency): ❑ First line therapy: IV lorazepam (0.1 mg/kg, rate not critical, 4 mg bolus) OR ❑ Second line therapy: Buccal midazolam (10 mg) or rectal diazepam (10-20 mg) if IV access could not be established or IV lorazepam is not available

Recurrent or ongoing seizure 10 min after onset? (Emergency) ❑ Repeat the previous regimen only ONCE

Recurrent or ongoing seizure 30 mins after onset? (Emergency) ❑ IV phenytoin (15-18 mg/kg at 50 mg/min): Slow IV infusion, IM is not recommended, monitor ECG during the infusion OR ❑ IV fosphenytoin (15-20 mg phenytoin equivalents (PE)/kg at 50-100 mg PE/min): monitor ECG during the infusion OR ❑ IV phenobarbital (10-15 mg/kg at 100 mg/min)

Ongoing seizure 60 mins after onset? (Emergency) Start anesthesia (reduce the doses after 2-3 days): ❑ Midazolam (0.1-0.2 mg/kg bolus, then 0.05-0.5 mg/kg/hour) titrated to effect OR ❑ Thiopental (3-5 mg/kg bolus, then 3-5 mg/kg/hour) titrated to effect OR ❑ Propofol (1-2 mg/kg bolus, then 2-10 mg/kg/hour) titrated to effect Ensure full intensive care support ❑ Intubate ❑ ICU admission and continuous monitoring

Adapted from the 2012 National Institute for Health and Care Excellence (NICE) clinical guidelines.

References

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