- 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. (Previous definitions used a 30-minute time limit)
- Overall mortality is high (22%)
- 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
- Epileptic seizure
- Non-epileptic seizure
- Brain abscess
- Intracranial hemorrhage
- Alcohol withdrawal
- Benzodiazepine withdrawal
- Barbiturate withdrawal
- Baclofen withdrawal
- Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia, hepatic failure, uremia
- Posterior reversible encephalopathy syndrome
- Impact seizure (head trauma)
- Acute hydrocephalus
- Arteriovenous malformation
- Seizure with VP shunt
- Toxic ingestion (amphetamines, anticholinergics, cocaine, INH, organophosphates, TCA, salicylates, lithium, phenothiazines, bupropion, camphor, clozapine, cyclosporine, fluoroquinolones, imipenem, lead, lidocaine, metronidazole, synthetic cannabinoids, theophylline, Starfruit)
- Psychogenic nonepileptic seizure (pseudoseizure)
- Intracranial mass
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Post-hypoxic myoclonus (Status myoclonicus)
- Clinical diagnosis
- Consider emergent CT head, plus/minus LP
- Consider the following labs:
- Repeat glucose checks
- Electrolytes including Na, Ca, Mg
- Tox screen
- Serum beta HCG
- Anti-seizure medication levels
- 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
- Benzodiazepine (Initial treatment of choice)
- Secondary medications
- ESETT trial compared second line antiseizure medications and they all are equally efficacious. Therefor may be best to use the one with least side effects  which is Levetiracetam
- Levetiracetam IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred in pregnancy)
- 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
- Avoid phenytoin or fosphenytoin in suspected toxicology case due to sodium channel blockade
- Valproic acid IV 20-40 mg/kg at 5 mg/kg/min, max 3000 mg (avoid 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
- Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV
- Phenobarbital IV 15-20 mg/kg at 50-75 mg/min
- 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)
- Secondary causes of seizure (e.g. hyponatremia, hypoglycemia, INH toxicity, ecclampsia)
- Nonconvulsive seizures or status epilepticus - get EEG
- Admit to ICU or intermediate level of monitored care depending on etiology, treatments and respiratory status
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- Kapur J, Elm J, Chamberlain J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103-2113. doi:10.1056/NEJMoa1905795
- PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
- Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
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