Status epilepticus resident survival guide: Difference between revisions
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'''Consider alternative diagnosis:'''<br> | '''Consider alternative diagnosis:'''<br> | ||
❑ Psychogenic non-epileptic seizures<br> | ❑ Psychogenic non-epileptic seizures (review the medical chart of the patient)<br> | ||
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'''Treat acidosis if severe''' | '''Treat acidosis if severe''' |
Revision as of 14:59, 19 December 2013
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.[1]
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
- Alcoholism
- 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[2][1]
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 ❑ Maintain blood pressure ❑ Establish IV access ❑ Institute regular monitoring for pulse, blood pressure, temperature ❑ ECG monitoring ❑ Check fingerstick glucose, and correct hypoglycemia if present (Emergency) Order labs: Consider vitamin deficiencies: Consider alternative diagnosis: Treat acidosis if severe | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Administer AED (Emergency): | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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): Ensure full intensive care support | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Adapted from the 2012 National Institute for Health and Care Excellence (NICE) clinical guidelines.
Do's
- Make sure to secure airway and maintain blood pressure within normal ranges, then administer anticonvulsants and then proceed to complete the diagnostic workup.[4]
- In the case of seizures lasting more than 5 minutes, it is beneficial do begin pre-hospital treatment with rectal diazepam among adults and children known to have frequent seizure episodes. Intravenous lorazepam or diazepam can be started by well-trained teams of paramedics during the pre-hospital care of patients with seizures lasting more than 5 minutes.[4]
Dont's
- Don't delay the initiation of treatment during the initial diagnostic evaluation.[4]
References
- ↑ 1.0 1.1 Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T; et al. (2012). "Guidelines for the evaluation and management of status epilepticus". Neurocrit Care. 17 (1): 3–23. doi:10.1007/s12028-012-9695-z. PMID 22528274.
- ↑ Trinka E, Höfler J, Zerbs A (2012). "Causes of status epilepticus". Epilepsia. 53 Suppl 4: 127–38. doi:10.1111/j.1528-1167.2012.03622.x. PMID 22946730.
- ↑ Lowenstein DH, Alldredge BK (1998). "Status epilepticus". N Engl J Med. 338 (14): 970–6. doi:10.1056/NEJM199804023381407. PMID 9521986.
- ↑ 4.0 4.1 4.2 4.3 Chen JW, Wasterlain CG (2006). "Status epilepticus: pathophysiology and management in adults". Lancet Neurol. 5 (3): 246–56. doi:10.1016/S1474-4422(06)70374-X. PMID 16488380.