Status epilepticus

Background

  • Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments or recurrent seizure activity without return to baseline mental status.[1][2] (Previous definitions used a 30-minute time limit)[3]
  • Overall mortality is high (22%)[4]
  • Divided in generalized convulsive status epilepticus (GCSE) and nonconvulsive status epilepticus (NCSE)
    • NCSE presents as an alteration in behavior associated with subtle changes (as twitching, blinking, eye deviation, aphasia, somatosensory findings) and continuous epileptiform discharges on EEG

Clinical Features

  • Seizure > 20 minutes. [5]
  • Presume status in current seizure > 5 minutes[6]

Differential Diagnosis

Seizure

Evaluation

  • Clinical diagnosis

Managment

Seizure Precautions

  • Protect patient from injury
    • If possible, place patient in left lateral position to reduce risk of aspiration
    • Do not place bite block!
  • Jaw thrust, a NPA and oxygen may be required
  • An IV line should be placed

Medications

  • Benzodiazepine (Initial treatment of choice)[7]
    • Midazolam IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg[8] - may also be given IN
    • Lorazepam IV 2 mg or 0.1 mg/kg
    • Diazepam IV 0.15-0.2 mg/kg (up to 10 mg) or PR 0.2-0.5 mg/kg (up to 20 mg)
  • Secondary medications
    • Phenytoin IV 18 mg/kg at ≤ 50 mg/min
    • Fosphenytoin IV 20-30 mg/kg at 150 mg/min (may also be given IM)
      • Contraindicated in pts w/ 2nd or 3rd degree AV block
    • Valproic acid IV 20-40 mg/kg at 5 mg/kg/min (avoid in pregnancy)
    • Levetiracetam IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred in pregnancy)
  • Refractory medications
    • Propofol 2-5mg/kg, then infusion of 2-10mg/kg/hr OR
    • Midazolam 0.2mg/kg, then infusion of 0.05-2mg/kg/hr OR
    • Ketamine loading dose 0.5 to 3 mg/kg, followed by infusion of 0.3 to 4 mg/kg/hr[9]
    • Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV[10]
    • Phenobarbital IV 15-20 mg/kg at 50-75 mg/min[11]
      • Then continuous infusion at 0.5-4.0 mg/kg/hr
      • Dose adjusted to suppression-burst pattern on continuous EEG
    • Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)[12]
  • Others

Other Considerations

Disposition

  • Admit to ICU or intermediate level of monitored care depending on etiology, treatments and respiratory status

External Links

See Also

References

  1. Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9
  2. Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8
  3. Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.
  4. Martindale JL, Goldstein JN, Pallin DJ. Emergency department seizure epidemiology. Emerg Med Clin North Am. 2011 Feb;29(1):15-27.
  5. Brodie MJ. Status epilepticus in adults. Lancet. 1990 Sep 1; 336(8714):551-2.
  6. Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med. 1998; 338:970-976
  7. Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016; 16(1):48-61.
  8. McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582
  9. Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
  10. Legros B et al. Intravenous lacosamide in refractory seizure clusters and status epilepticus: comparison of 200 and 400 mg loading doses. Neurocrit Care. 2014 Jun;20(3):484-8.
  11. Pugin D et al. Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study. Critical Care 2014. DOI: 10.1186/cc13883.
  12. Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.