15.14 Status Epilepticus

Question 1

You are asked to review a 27-year-old male who is a known epileptic in convulsive status epilepticus.

a) Define convulsive status epilepticus. (1 mark)

Answer 1

> > Seizure activity lasting more than five minutes,

or more than three seizures in one hour.

Question 2

b) Outline your initial management of this patient, including the use of emergency antiepileptic drug
therapy. (7 marks)

Answer 2

Status epilepticus is a medical emergency
and I would adopt an ABC approach,
assessing and managing the patient simultaneously. Antiepileptic drugs must be given without delay.

> > A and B: 15 l/min oxygen via
non-rebreathe mask.
Assess airway patency and proceed to
RSI if patient unable to protect own airway.
Continuous oxygen saturations monitoring.

> > C: large-bore intravenous access,
continuous ECG monitoring,
noninvasive blood pressure monitoring
until arterial line sited.

> > Lorazepam 0.1 mg/kg IV (approximately 4 mg).

> > Investigations:
arterial blood gas,
blood glucose,
urea and electrolytes,
calcium and magnesium,
coagulation,
full blood count,
antiepileptic drug
(AED) levels.

> > Give usual AED if feasible.

> > Repeat lorazepam after 10–20 minutes.

> > Treat acidosis if severe.

> > Consider pabrinex and glucose
(50 ml 50%) if any possibility of alcohol
excess or malnutrition.

> > Phenytoin or fosphenytoin IV.

Question 3

c) 60 minutes after your initial management, the patient continues in status epilepticus. What would be
your further management? (5 marks)

Answer 3

This is now refractory status:

> > Rapid sequence induction
using propofol or thiopentone bolus
followed by infusion.

> > ICU care with EEG monitoring.

> > CXR to check intubation and
to check for aspiration.

> > Identify and treat medical
complications of status.

> > Consider possible non-epileptic underlying cause or trigger.
Consider need for brain imaging or lumbar puncture

Question 4

d) What are the complications associated with refractory convulsive status epilepticus? (7 marks)

Answer 4

Airway:
» Oral soft tissue injury or dental damage.
» Obstruction.

Respiratory:
» Aspiration.
» Pneumonia.
» Respiratory failure.
» Pulmonary oedema.

Cardiac:
» Myocardial infarction.
» Hyper- or hypotension.
» Arrhythmias.
» Cardiac arrest.
» Cardiogenic shock.

Neurological:
» Cerebral hypoxia.
» Cerebral oedema.
» Cerebral haemorrhage.
» Excitotoxic CNS injury.

Haematology:
» DIC.

Musculoskeletal:
» Fractures.
» Rhabdomyolysis.

Renal:
» Acute kidney injury.

Hepatic:
» Acute liver injury.

Metabolic:
» Hyponatraemia.
» Hypoglycaemia.
» Hyperkalaemia.
» Metabolic acidosis.
» Hyperthermia.