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 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 trauma
• Cerebrovascular disorders
• Electrolytes abnormalities
• Hypoglycemia
• Infections
• Low antiepileptic drug levels in patients with epilepsy

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 ❑ 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 (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 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? (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) ❑ 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

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

References

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