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 a seizure persisting longer than 5 minutes or 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.

Management

Shown below is an algorithm summarizing the approach to status epilepticus.

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 ❑ Tounge bite and/or ❑ Incontinence

General measures (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 glucose level, and correct hypoglycemia if present (Urgent) Order labs: ❑ Full blood count ❑ Plasma electrolytes ❑ Blood gases ❑ Glucose ❑ Renal and liver function ❑ Serum calcium and magnesium ❑ Blood clotting br> ❑ 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 the possibility of non-epileptic status Treat acidosis if severe

Administer AED (Emergency): ❑ First line therapy: IV lorazepam (0.1 mg/kg at 2 mg/min, 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? (Urgent) ❑ Repeat the previous regimen only ONCE

Recurrent or ongoing seizure 30 mins after onset? (Urgent) ❑ 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? (Urgent) ❑ Intubate and ensure full intensive care support ❑ Anesthetize with midazolam (0.1-0.2 mg/kg bolus, then 0.05-0.5 mg/kg/hour), OR thiopental (3-5 mg/kg bolus, then 3-5 mg/kg/hour, OR propofol (1-2 mg/kg bolus, then 2-10 mg/kg/hour) titrated to effect; reduce the dose after 2-3 days as fat stores are saturated ❑ ICU admission

References

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