Status Epilepticus

Question 1

ILAE definition of status epilepticus:

Answer 1

SE is a condition resulting either from:

• failure of the mechanism responsible for seizure termination
• the initiation of mechanisms which leads to abnormally prolonged seizures
  (after time point t1)

SE is a condition that can have long-term consequences including:

• neuronal death
• neuronal injury
• alteration of neuronal networks
• functional deficits
  (after time point t2)

Question 2

SE

• Homeostatic mechanism

Answer 2

Homeostatic mechanism is lost, and glutamate is released in massive amounts

• Calcium influx
• Release of neurotransmitters
• Excess depolarization

Also unable to increase blood flow to the brain

• Vital signs: BP, HR etc.
• Result in hypoxia, thus require oxygenation
• Result in hypoglycemia

Question 3

Tonic-clonic status epilepticus

• What are the time points T1 and T2, and what are the implications?

Answer 3

T1: 5min

• Indicates the time that emergency treatment should be started as seizure is likely to be prolonged leading to continuous seizure activity

T2: 30min

• Indicates the time at which long-term consequences may be expected (neuronal death, neuronal injury, alteration of neuronal networks, functional deficits)

Question 4

What are the four phases of SE treatment?

Answer 4

1. Stabilization phase (0-5min)
2. Initial therapy phase (5-20min)
3. Second therapy phase (20-40min)
4. Third therapy phase (40-60min)

Question 5

Stabilization phase (0-5min)

Answer 5

• Stabilize patient (breathing, circulation, disability)
• Monitor vital signs
• Assess oxygenation
• Initiate ECG monitoring
• Collect finger stick blood glucose, ensure no hypoglycemia (treat with thiamine, dextrose if glucose <60mg/dl)
• Attempt IV access and collect electrolytes, hematology toxicology screen

Question 6

Initial therapy phase (5-20min)

• Given seizure continued past 5min

Answer 6

First line: Benzodiazepine

• IM Midazolam (SA) - single dose
• IV Lorazepam (IA) - may repeat dose once
• IV Diazepam (LA) - may repeat dose once

If BZD not available,

• IV Phenobarbital - single dose
• Rectal Diazepam - single dose
• Intranasal/Buccal Midazolam

Question 7

Second therapy phase (20-40min)

Answer 7

No evidence-based preferred for second therapy of choice

Single dose of one of the following:

• IV Phenytoin
• IV Valproic acid
• IV Levetiracetam

(among the agents, may add on as well)

If none available,

• IV Phenobarbital

Question 8

Third therapy phase (40-60min)

Answer 8

No clear evidence to guide therapy

• May repeat second line therapy
• May try anesthetic doses of thiopental, midazolam, pentobarbital, or propofol (all with continuous EEG monitoring)