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Samuel SS

Case 3B

Emergency Medicine

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Glasgow Coma Scale

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Status Epilepticus

Seizures lasting >30 minutes

Regain no conciousness between seizures

Medical emergency requiring rapid management

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Etiology

Primary neurologic lesions : Neurovascular (stroke, AVM)

Tumor

CNS infection

Head injury

Epilepsy

Non primary neurologic lesions :

Hypoxia/ischemic Drug toxicity (antibiotic, antidepressant, antipsychotic)

Febrile seizure

Metabolic disease

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Neurologic

changes in SE

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Diagnose SE

Anamnesis (alloanamnesis)

Type of

seizure

Consciousness

AutomatismPostictal periode ?Ethiology

Medicine

Infection

Trauma

History of seizure

?

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Physical examination

Neurological

examination

GCS

Pupil

Meningeal signTriad cushing sign

Vital sign

BP

HR

RR

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other examination

laboratory

Blood glucose

Electrolyte

Drug intoxicated

RBC

EEG Continue in 24 h

CT brain / MRISuspected focal

lession

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Initial investigations

Labs

Na, Ca, Mg, PO4 , glucose

CBC

Liver function tests, ammonia

Anticonvulsant level

Toxicology

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Initial investigations

Lumbar puncture

Always defer LP in unstable patient, but never delay

antibiotic / antiviral rx if indicated

CT scan Indicated for focal seizures or deficit, history of trauma or

bleeding d/o

http://content.nejm.org/content/vol338/issue14/images/large/07f1.jpeg

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Treatment

http://content.nejm.org/content/vol338/issue14/images/large/07f1.jpeghttp://content.nejm.org/content/vol338/issue14/images/large/07f1.jpeg

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30-90 minutes

For refractory GCSE (after failure of 2 AEDs)

Intubation is necessary at this point. Paralysis is not usually necessary,

as the continous infusion will usually be adequately sedatig.

Continous infusion therapy :

Phenobarbital 5mg/kg over 10 minutes until seizures stop,then

continue 1-15mg/kg/hour

Midazolam 0.2 mg/kg q5 minutes until seizures stop, then

continue 0.1 up to max of 3 mg/kg/hour

replete prior AEDs, if love serum levels

identify and treat any medical conditions

Hypertonic saline if sever hyponatremia is present

IV calcium if serious hypocalcemia present

30-90 minutes

for NCSE, focal SE, and when intubation is to be avoided :

Third line therapi : Phenobarbital 20 mg/kg IV at 75 mg/min

Valproate 30mg/kg IV over 5 minutes

Levetiracetam 2mg/kg IV over 15 minutes

Remember to follow initial boluses with maintenance doses

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Seizure First Help

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Complications

CNS

Cerebral hypoxia

Cerebral edema

Cerebral bleeding

Cardiovascular

MI

Arrhythmia

Cardiac arrest

Respiration

Aspiration pneumonia

Pulmonary hypertension

Lung emboly

Metabolic

Dehydration

Electrolyte disturbance

Acute tubular necrosis

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Prognosis

Prognosis is related most strongly to the underlying

process causing SE

SE from anticonvulsant irregularity/those with

alcohol-related seizures favorable prognosis iftreatment is commenced rapidly and complications

are prevented.

SE caused by anoxia/hypoxia poor prognosis