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

• 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

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 ❑ Rapid jerky movement ❑ Uprolling of eyes ❑ Tongue bite ❑ Incontinence Determine the onset of symptoms: ❑ Ask a witness

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: ❑ 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 or isoniazid toxicity Consider alternative diagnosis: ❑ Psychogenic non-epileptic seizures (review the medical chart of the patient) 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 (0.2 mg/kg bolus, slow bolus, then 0.05-0.5 mg/kg/hour) titrated to effect OR ❑ Propofol (1-2 mg/kg bolus, then 2-10 mg/kg/hour) titrated to effect OR ❑ Thiopental (3-5 mg/kg bolus, then 3-5 mg/kg/hour) titrated to effect Ensure full intensive care support ❑ Intubate ❑ ICU admission ❑ Place EEG monitoring ❑ Place arterial catheter and central catheter if indicated ❑ Monitor complications: hyperthermia, hypertension, tachycardia, arrhythmia, hypoxia, metabolic acidosis, hyperkalemia, hyperglycemia, hypoglycemia, high output cardiac failure, pulmonary edema, pulmonary hypertension

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.
• 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.
• The initial treatment with benzodiazepines ( lorazepam, midazolam or diazepam) may be repeated once 10 minutes following the first administered dose.

Dont's

• Don't delay the initiation of treatment during the initial diagnostic evaluation.

References

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