Status Epilepticus

Question 1

Status epilepticus refers to …

Answer 1

Status epilepticus refers to continuous seizure activity, which has failed to self-terminate.

Question 2

Status epilepticus (SE) or ‘status’ is medical emergency. More than …% of patients with epilepsy will have at least one episode of SE, which can be life-threatening. It is traditionally defined by the duration of continuous seizure activity and effect on consciousness.

Answer 2

Status epilepticus (SE) or ‘status’ is medical emergency. More than 15% of patients with epilepsy will have at least one episode of SE, which can be life-threatening. It is traditionally defined by the duration of continuous seizure activity and effect on consciousness.

Question 3

Traditional definition of status epilepticus

Answer 3

A single epileptic seizure lasting > 30 minutes

A run of epileptic seizures (≥2) without regaining consciousness between episodes

Question 4

The majority of seizures will spontaneously terminate within 3 minutes and do not require emergency treatment. However, those with sustained seizures are at risk of long-term neurological damage. The highest risk is with generalised …

Answer 4

The majority of seizures will spontaneously terminate within 3 minutes and do not require emergency treatment. However, those with sustained seizures are at risk of long-term neurological damage. The highest risk is with generalised tonic-clonic seizures.

Question 5

Instead, patients should be treated as SE if they have the following: (2)

Answer 5

A convulsive seizure lasting > 5 minutes

Recurring seizures without recovery

Question 6

Status epilepticus can be divided into …

Answer 6

Status epilepticus can be divided into convulsive and non-convulsive status.

Question 7

Convulsive SE

Answer 7

Convulsive SE is used to describe the typical, sustained generalised tonic-clonic seizure, which presents with generalised muscle stiffening and rhythmic muscle jerking. Other types may include myoclonic status, tonic status and focal motor status.

A background of epilepsy is single strongest risk factor for generalised convulsive SE

Question 8

Non-convulsive SE

Answer 8

Non-convulsive SE is used to describe a long or repeated absence or focal impaired awareness seizure. These patients do not have classical convulsive movements that make it easy to recognise. Instead, it usually requires a high degree of suspicion and evidence of epileptiform activity on electroencephalogram (EEG).

Clinical features may include altered mental status, subtle twitching or myoclonic jerks, unusual behaviour or speech disturbance.

Question 9

Basic seizure first aid:

Answer 9

STAY: remain with the patient until recovery, note the time, call for help (if needed)
SAFE: keep the patient safe, move or guide from harms way
SIDE: turn patient on their side, keep airway clear, cushion head, loosen tight fitting clothes
DON’T: restrain, place items in mouth
CONSIDER: rescue medications* if a trained medical professional or trained carer
CALL: 999 if seizure > 5 minutes, no return to normal state, injured, pregnant or sick, first seizure, repeated seizures, difficulty in breathing, seizure in water.

Question 10

Any seizure in hospital should be treated as a medical emergency.

Answer 10

In a hospital setting, it may be difficult to determine whether a seizure will spontaneously terminate or require treatment for SE. This is especially true if a seizure is witnessed or there is no delay in assessment (< 5 minutes). Therefore, any seizure developing in hospital should be treated as a medical emergency and managed with a structured ABCDE approach.

We can divide the assessment and management of seizures into different stages based on seizure duration.

Question 11

1st stage (0-10 minutes): early status

Answer 11

Check for safety and call for help
Assess the patient with respect to ABCDE (airway, breathing, circulation, disability, exposure)
Protect the airway and provide oxygen therapy
Protect the patient, but do not restrain
Establish IV access*

Question 12

2nd stage (0-30 minutes)

Answer 12

Regular monitoring (e.g. cycling observations, ECG monitoring if possible, temperature)
Emergency AED therapy (see acute seizure management)
Emergency investigations (bloods, CXR, toxicology screen)
Consider alcohol intoxication: consider Parbinex
Blood glucose level: consider intravenous glucose (e.g. 100 mls 20%)

Question 13

3rd stage (0-60 minutes): established status

Answer 13

Determine aetiology (collateral history, hospital records, etc)
Further emergency AEDs as needed (see acute seizure management)
Alert anaesthetic team and intensive treatment unit (ITU)
Treat any co-morbidities (i.e. sepsis)
Consider urgent CT head (e.g. exclude intracerebral bleed, structural abnormalities)

Question 14

4th stage (30-90 minutes): refractory status

Answer 14

Transfer to ITU: requires general anaesthesia with intubation and ventilation
EEG monitoring

Question 15

Acute seizure management

Answer 15

Emergency anti-epileptic drugs are critical to seizure control.

Question 16

Benzodiazepines are the cornerstone of initial seizure treatment. It is essential to check whether any pre-hospital benzodiazepines have already been administered.

For adults:

Answer 16

Lorazepam 4 mg IV, if unavailable;
Diazepam 10 mg PR, if unavailable;
Midazolam 10 mg buccal

Question 17

A further single dose of benzodiazepine can be administered within 10-20 minutes if seizures have not been controlled. Ensure usual AEDs have been administered.

For adults:

Answer 17

Lorazepam 4 mg IV, if unavailable;
Diazepam 10 mg PR, if unavailable;
Midazolam 10 mg buccal

Question 18

If the seizure has not been controlled by two doses of benzodiazepine, patients require loading (i.e. IV infusion) of a 2nd line ,…

Answer 18

If the seizure has not been controlled by two doses of benzodiazepine, patients require loading (i.e. IV infusion) of a 2nd line AED.

Question 19

At present, … is the only licensed agent, but other AEDs are being increasingly used. Always check local hospital SE guidelines.

For adults:

Answer 19

Phenytoin: 20 mg/kg, requires ECG monitoring. May be preferred if contraindications to alternatives or already established on phenytoin and suspected poor adherence. Key side-effects: hypotension, bradycardia, heart block

Question 20

Refractory status

Answer 20

If a patient is refractory to previous medications, they should be referred to ITU for general anaesthesia with intubation and ventilation. Anaesthesia should be continued for a minimum of 12-24 hours and guided by EEG monitoring.

Options:

Propofol
Midazolam
Thiopental sodium

Question 21

All patients with … should be discussed with the specialist neurology team and ideally reviewed within 24 hours.

Answer 21

All patients with SE should be discussed with the specialist neurology team and ideally reviewed within 24 hours.

Question 22

Major acute complications of SE include:

Answer 22

Acute: hyperthermia, cardiac arrhythmias, severe hypoxaemia, shock, cerebral oedema
Chronic: long-term neurological damage (epilepsy, focal neurological deficits, encephalopathy)