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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