A21. Status epilepticus

Question 1

Status epilepticus is defined as

Answer 1

• 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

Question 2

A new guideline recommends that seizures lasting longer than 5 minutes should be treated as

Answer 2

status
epilepticus

Question 3

Classification of status epilepticus

Answer 3

• 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.)

Question 4

different presentations of status epilepticus With prominent motor feature

Answer 4

Convulsive (tonic-clonic)
Myoclonic (with or without coma)
Tonic
Hyperkinetic
Focal motor (focal convulsive status epilepticus)

Question 5

presentation of status epilepticus Without prominent motor features: nonconvulsive status epilepticus (NCSE)

Answer 5

• With coma
• Without coma
  *Absence
  *Focal (e.g., aphasia, impaired consciousness, ongoing autonomic or sensory symptoms)

Question 6

Generalized convulsive status epilepticus different presentations

Answer 6

○ Generalized tonic-clonic seizures, mortality: 30%
○ Myoclonic seizures (often in post-hypoxic states), mortality: 50-86%
○ Tonic seizures
○ Clonic seizures

Question 7

Focal convulsive status epilepticus
- different presentations

Answer 7

○ Epilepsia partialis continua (Kozhevnikov’s syndrome)
○ Hemi-convulsion

Question 8

different presentations of Non-convulsive status epilepticus

Answer 8

○ Absence status epilepticus
○ Generalized electrographic status epilepticus
○ May occur with retained or impaired awareness

Question 9

causes of Status epilepticus in children

Answer 9

● Childhood
○Fever
○Infection

Question 10

causes of Status epilepticus in adults

Answer 10

● Adult
○ Antiepileptic drug withdrawal
○ Acute cerebral embolization
○ Metabolic disorder
○ Alcohol intoxication
○ Tumor
○ Neuroinfection

Question 11

diagnostic tool used in Status epilepticus

Answer 11

EEG electroencephalogram

Question 12

in clinically obvious cases of status epilepticus do you wait for EEG to start medications?

Answer 12

• medical treatment should be started immediately, even before the
  diagnosis by EEG

Question 13

termination of status epilepticus must be confirmed by

Answer 13

EEG (due to non-convulsive or
electrographic status epilepticus)

Question 14

EEG uses in status epilepticus

Answer 14

• helps monitoring the effect of AED(antiepileptic drugs) treatment and
• shows the level anesthesia in patients requiring anesthesia

Question 15

why is treatment similar in both focal status epilepticus and generalized status epilepticus?

Answer 15

The risk of a focal status epilepticus turning in to a generalized one is relatively high, therefore
treatment is similar in both forms

Question 16

Aims in status epilepticus is to

Answer 16

stabilize vital functions
and
stop the seizures

Question 17

when to initiate Pharmacological treatment in status epilepticus

Answer 17

should be started as soon as possible

Question 18

Name of treatment protocol for status epilepticus

Answer 18

(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)

Question 19

status epilepticus Treatment protocol 0-5 minutes

Answer 19

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

Question 20

status epilepticus 5-20 minutes
treatment protocol

Answer 20

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

Question 21

status epilepticus 20-40 minutes
treatment protocol

Answer 21

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

Question 22

status epilepticus 40-60 minutes
treatment protocol

Answer 22

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

Question 23

If the seizures stop after any of the phases (clinically and on the EEG), is symptomatic care continued ?

Answer 23

normal symptomatic medical
care should be continued.

Question 24

if benzo not available in Initial therapy phase of status epilepticus what are alternatives?

Answer 24

● Phenobarbital i.v.
● Diazepam p.r. (Level B)
● Midazolam i.n. or buccal (Level B)

Question 25

which benzos are used in status epilepticus? and in which phase?

Answer 25

● 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