A21. Status epilepticus Flashcards
Status epilepticus is defined as
- one continuous unremitting seizure
- lasting for longer than 30 minutes, or
- recurrent seizures where consciousness is not regained between seizures for longer than 30 minutes.
A new guideline recommends that seizures lasting longer than 5 minutes should be treated as status
epilepticus
A new guideline recommends that seizures lasting longer than 5 minutes should be treated as
status
epilepticus
Classification of status epilepticus
- With prominent motor features (Motor features may diminish during the course of the event, but seizure activity will still be visible on EEG.)
-
Without prominent motor features: **nonconvulsive status epilepticus (NCSE) **
(Subtle motor features, such as eyelid or orofacial myoclonus, may be present.)
different presentations of status epilepticus With prominent motor feature
Convulsive (tonic-clonic)
Myoclonic (with or without coma)
Tonic
Hyperkinetic
Focal motor (focal convulsive status epilepticus)
presentation of status epilepticus Without prominent motor features: nonconvulsive status epilepticus (NCSE)
- With coma
- Without coma
*Absence
*Focal (e.g., aphasia, impaired consciousness, ongoing autonomic or sensory symptoms)
Generalized convulsive status epilepticus different presentations
○ Generalized tonic-clonic seizures, mortality: 30%
○ Myoclonic seizures (often in post-hypoxic states), mortality: 50-86%
○ Tonic seizures
○ Clonic seizures
Focal convulsive status epilepticus
- different presentations
○ Epilepsia partialis continua (Kozhevnikov’s syndrome)
○ Hemi-convulsion
different presentations of Non-convulsive status epilepticus
○ Absence status epilepticus
○ Generalized electrographic status epilepticus
○ May occur with retained or impaired awareness
causes of Status epilepticus in children
● Childhood
○Fever
○Infection
causes of Status epilepticus in adults
● Adult
○ Antiepileptic drug withdrawal
○ Acute cerebral embolization
○ Metabolic disorder
○ Alcohol intoxication
○ Tumor
○ Neuroinfection
diagnostic tool used in Status epilepticus
EEG electroencephalogram
in clinically obvious cases of status epilepticus do you wait for EEG to start medications?
- medical treatment should be started immediately, even before the
diagnosis by EEG
termination of status epilepticus must be confirmed by
EEG (due to non-convulsive or
electrographic status epilepticus)
EEG uses in status epilepticus
- helps monitoring the effect of AED(antiepileptic drugs) treatment and
- shows the level anesthesia in patients requiring anesthesia
why is treatment similar in both focal status epilepticus and generalized status epilepticus?
The risk of a focal status epilepticus turning in to a generalized one is relatively high, therefore
treatment is similar in both forms
Aims in status epilepticus is to
stabilize vital functions
and
stop the seizures
when to initiate Pharmacological treatment in status epilepticus
should be started as soon as possible
Name of treatment protocol for status epilepticus
(American Epilepsy Society)
* based on timeline
*0-5 min (stabilization phase)
*5-20 mins(Initial therapy phase)
*20-40 mins (Second therapy phase)
*40-60 mins (Third therapy phase)
status epilepticus Treatment protocol 0-5 minutes
Stabilization phase
1. Stabilize patient (ABCDE)
2. Time the seizure from its onset, monitor vital signs
3. Assess oxygenation, give O 2 , consider intubation if needed
4. Initiate ECG monitoring
5. Measure blood glucose, if glucose < 60 mg/dl then administer 100 mg thiamine i.v. and glucose
6. Attempt i.v. access and collect electrolytes, hematology, toxicology screen, AED levels
status epilepticus 5-20 minutes
treatment protocol
Initial therapy phase
A benzodiazepine is the initial therapy of choice (Level A)
1 st line: one of the following
● Midazolam i.m. (10mg)
● Lorazepam i.v. (0,1 mg/kg)
● Diazepam i.v. (0,15-0,2 mg/kg)
If not available, choose one of the following
● Phenobarbital i.v.
● Diazepam p.r. (Level B)
● Midazolam i.n. or buccal (Level B)
*Level A: established as effective
*Level B: probably effective
*Level U: insufficient data
status epilepticus 20-40 minutes
treatment protocol
Second therapy phase
Choose one of the following 2 nd line options, a single dose
● Fosphenytoin i.v.
● Valproic acid i.v. (Level B)
● Levetiracetam i.v.
If not available
● Phenobarbital i.v. (Level B)
There is no evidence based preferred second therapy of choice (Level U)
*Level A: established as effective
*Level B: probably effective
*Level U: insufficient data
status epilepticus 40-60 minutes
treatment protocol
Third therapy phase
Choices include:
● Repeat second line therapy:
*Fosphenytoin i.v.
*Valproic acid i.v. (Level B)
*Levetiracetam i.v.
If not available :Phenobarbital i.v. (Level B)
● Anesthetic doses of either *thiopental,
*midazolam,
*pentobarbital
*or propofol (with continuous EEG
monitoring)
There is no clear evidence to guide therapy in this phase (Level U)
*Level A: established as effective
*Level B: probably effective
*Level U: insufficient data
If the seizures stop after any of the phases (clinically and on the EEG), is symptomatic care continued ?
normal symptomatic medical
care should be continued.
if benzo not available in Initial therapy phase of status epilepticus what are alternatives?
● Phenobarbital i.v.
● Diazepam p.r. (Level B)
● Midazolam i.n. or buccal (Level B)
which benzos are used in status epilepticus? and in which phase?
● Midazolam i.m. (10mg)
● Lorazepam i.v. (0,1 mg/kg)
● Diazepam i.v. (0,15-0,2 mg/kg)
in Initial therapy phase 5-20 minutes
