STATUS EPILEPTICUS

seizure is a paroxysmal event due to abnormal excessive or synchronous neuronal activity in the brain

Epilepsy describes a condition in which a person has recurrent seizures due to a chronic, underlying process

two or more unprovoked seizures

STATUS EPILEPTICUS

Traditional Definition

Continuous seizures or repetitive, discrete

seizures with impaired consciousness in the

inter-ictal period.

Duration of seizure activity should be 15-30

min.

SUBTYPES

Convulsive Status Epilepticus simple partial motor status epilepticuscomplex partial status epilepticus with clonic motor manifestationsgeneralized myoclonic, generalized tonic, generalized clonic, and generalized tonic-clonic

Nonconvulsive Status Epilepticuscomplex partial status epilepticus without clonic activitygeneralized absence status epilepticus

?? 30-minute duration - may delay aggressive therapy

Irreversible neuronal injury may start after 20 to 30 minutes of GCSE

Practical Definition duration of seizures prompts the acute use of anticonvulsant therapyvigorous therapy for status epilepticus be initiated after 5 minutes of GTCS & complex partial seizures that last longer than 10 minutes

GCSE is an emergency and must be treated immediately

cardiorespiratory dysfunction, Hyperthermia metabolic derangements irreversible neuronal injury

Etiology

most common cause - anticonvulsant withdrawal or noncompliance

acute cerebrovascular accidents Metabolic CNS infection Alcohol/Drug toxicity Hypoxia

Continued…

Intra-cranial space occupying lesion Trauma Fever/infection

Acute Management of Seizures

Oxygen, oral airway. Avoid hypoxia!

Consider bag-valve mask ventilation. Consider intubation

IV/IO access. Treat hypotension, but NOT hypertension

AA

BB

CC

Common Sense:0-5 minutesStabilize the patient-

0-5 minutes….

Give glucose (100 ml D25%), unless normo- or hyperglycemic

Hyperglycemia has no negative effect in SE (as long as significant hyperosmolality is being avoided)

Thiamin 100 mg IV - if given D25 or if cachectic/malnourished/alcoholic

Initial investigations(0-5 minutes)….

Labs Na,K, Ca, Mg, PO4 , BUN, Cret, glucose CBC Liver function tests, ammonia Anticonvulsant level Toxicology Blood C/S

Initial screening history and Physical examination

Treatment (Pharmacotheraqpy)5-15 minutes..

The longer we wait with anticonvulsant, the more anticonvulsant we will need to stop SE

Most common mistake is ineffective dose

Anticonvulsants

Rapid acting

plus

Long acting

Anticonvulsants - Rapid acting

Benzodiazepines

Lorazepam 0.1- 0.15 mg/kg i.v upto 4-6 mg over 1-2 minutes

If SE persists, repeat every 5-10 minutes

If lorazepam is successful in stopping GCSE, the decision to add another agent depends on the underlying etiology.

Lorazepam’s durationof action is approximately 12 to 24 hours.

If the etiologyis reversible (e.g., status epilepticus due to metabolic or toxic factors), lorazepam may be the only treatment necessary.

Another longer-acting AED is needed if the underlying etiology is not rapidly reversible

Seizures continuing / Stage of Established Seizure 15 – 35 min

In patients taking Valproate 25mg/kg iv in patients normally taking

valproate and who may be sub therapeutic

Continued…

Seizures continuing / Stage of Established Seizure 15 – 35 min

Phenytoin:- 20mg/kg Bolus dose IV at the

rate of 50mg/min. Fosphenytoin:- 20mg PE/kg Bolus dose IV

at the rate of 150mg/min

(Repeat dose of 10mg/kg can be given) Valproate:-25 mg/kg IV

Phenytoin 15-20 mg/kg i.v.

@50mg/min pH 12

Extravasation causes severe tissue injury

Onset 10-30 min May cause

hypotension, dysrhythmia

Cheap

Fosphenytoin 20 mg PE/kg i.v @

150mg/min Fosphenytoin 150

mg is equal to 100 mg phenytoin

pH 8.6Extravasation well tolerated

Onset 5-10 min May cause

hypotension Expensive

Seizures continuing / Stage of Refractory Status

-general anesthesia should be induced

Propofol:- 2mg/kg IV bolus,Repeat if necessary, followed by infusion (2 – 10 mg/kg/hr)

Thiopental:- 100-250mg IV bolus over 20 sec. with further 50mg bolus every 2-3 min.until seizure control followed by IV infusion(3-5mg/kg/hr)

Midazolam:- 0.3mg/kg IV bolus dose at the rate of 4mg/min, rpt every 5 min 3 doses followed by infusion(2 ug/kg/hr)

If seizures have been controlled for 12hrs., reduce the dose over further 12hrs.

If seizure recurs again GA agent should be given

MORTALITY

Adults Children

26%

3%

Reviewed in: Fountain NB. Epilepsia 2000;41 Suppl 2:S23-30Reviewed in: Fountain NB. Epilepsia 2000;41 Suppl 2:S23-30