STATUS EPILEPTICUS

BY Caroline Kanyingi
02:11:2020

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STATUS EPILEPTICUS (SE)
 Can be convulsive or nonconvulsive
 Convulsive status epilepticus is a medical emergency
defined as a generalised tonic-clonic convulsion that persists
for 30 minutes or longer, or is repeated frequently enough to
prevent recovery of consciousness between attacks.
• After 30 minutes of generalised tonic-clonic seizures, the
brain begins to suffer from hypoxia, acidosis, depletion of
local energy stores, cerebral oedema and structural
damage.

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SE (DIAGNOSTIC CRITERIA)
Usually Clinical, • Convulsive seizure lasting 30
minutes or longer. Convulsive seizures that have lasted
for 5 minutes or more should be managed as for Status.
Convulsive status epilepticus may be:
○ idiopathic
○ secondary to an insult to the brain, e.g.
encephalitis, hypoxic episode, trauma
○ as a result of non- compliance or changes in
anticonvulsant therapy

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Complications of SE
• Hyperpyrexia
• Disturbances of blood glucose
• Respiratory depression
• Renal failure
• Cerebral oedema
• Acidosis
• Blood pressure disturbances
• Inappropriate antidiuretic hormone (ADH) secretion
• Hypoxic, ischaemic damage to brain, myocardium and
muscles
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SE (Treatment)
A. NON-DRUG TREATMENT
Maintain an open airway
Place patient on side at 20–30° head up
Admit to HDU or ICU, if possible
If unconscious, consider catheterisation
Monitor: ○ heart rate ○ acid–base status
○ respiratory rate ○ blood gases ○ blood pressure
○ SpO2 ○ electrolytes ○ neurological status○ blood
glucose ○ fluid balance ○ anticonvulsant blood levels

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SE (Treatment)
NON DRUG TREATMENT Continued
 Administer oxygen 100 % to maintain SaO2 of ≥
95%
 Cardiovascular and/or respiratory support if the
patient is unable to maintain blood gases and blood
pressure within the normal physiological range
 Ventilation to maintain PaCO2 in the low normal
range, i.e. 4– 4.5 kPa

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PHARMACOLOGICAL MANAGEMENT
1 st stage (0-10mins).
i. Protect the patient e.g. padded bed rails.
ii. Do not restrain.
iii. Administer oxygen.
iv. During an inter-ictal period insert an airway and then administer oxygen.
Do not attempt to insert anything in the patient’s mouth during a seizure,
even if the tongue is injured. Place the patient in a semi-prone position with
the head down to prevent aspiration.
v. Establish iv access.
Note the time.

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2 nd Stage (0-30mins).
Institute regular monitoring (temperature, cardiac, respiration, BP).
Consider possibility of non-epileptic status. If there is any suggestion
of alcohol abuse or impaired nutrition, give thiamine as high potency
intravenous Pabrinex

BEFORE GLUCOSE. Estimate blood glucose rapidly using a blood

test. If the patient is hypoglycaemic, give 100ml of 10% glucose
rapidly, and if still fitting or unconscious, repeat and then start 10%
glucose at 100ml/hr.

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Emergency investigations:
venous blood count, clotting, glucose, urea, sodium, potassium,
calcium, liver function and anti-convulsant drug levels (irrespective of
known history at this stage).
Save 5ml blood and 50ml urine for toxicology. Treat acidosis if severe.
CXR to evaluate possible aspiration.

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3 rd Stage (0-60mins).
Establish aetiology:
i. Gain information (Is there evidence of previous epilepsy, any
anticonvulsant drugs, diary or wallet card or bracelet).
ii. Consider need for urgent CT (no previous epilepsy history, new focal
neurology, any refractory case).
iii. Alert anaesthetist and ICU.
iv. Identify and treat medical complications.
v. Consider pressor therapy if needed.

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4 th Stage (30-90mins).
Refractory status:
i. Transfer to ICU.
ii. Establish ICU monitoring & EEG if available

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DRUGS Check if any pre-hospital benzodiazepines have been given.
If two adequate doses of any benzodiazepine have been administered
and seizures have recurred within a 24-hour period, move straight to
2nd line/established status treatment.

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1. Early Status (0-10mins).
The drug of first choice is lorazepam given as an IV bolus injected at
2mg/min, ideally in a dose of 4mg for adults. If Lorazepam is
unavailable, give 10mg Diazepam iv or 10mg Buccal Midazolam.
If no iv access, give Buccal Midazolam.
A 2nd dose of a benzodiazepine may be repeated once within 10-
20minutes.
Give usual anti-epileptics if already on treatment.
NB: Benzodiazepines must be written up as ‘stat dose’ rather than ‘prn’.
Write up a maximum of two stat doses with clear instructions on when
to give, eg. ‘for convulsions > 5mins’ (not just ‘if fits’).

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2. Established status (10-30mins):
Alert the on-call anaesthetist in case of later need.
Start an iv infusion of a 2nd line antiepileptic agent.

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Drug Dose Preferred
Phenytoin 20mg/kg; 50mg/min Already taking Phenytoin,
suspected poor adherence
Alternatives contraindicated or
previously ineffective
Valproate 30mg/kg; 10mg/kg/min Already taking Valproate,
(3000mg) suspected poor adherence
Generalized epilepsy
Comorbid migraine, mood disorder
Alternatives contraindicated or
previously ineffective
Levetiracetam 40mg/kg; 6mg/kg/min Already taking Levetiracetam,
(4500mg) suspected poor adherence
Need for minimal drug interactions
Alternatives contraindicated or
previously ineffective
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contraindication
Significant hypotension
Bradycardia
Heart block
Porphyria
Generalized epilepsy*
Overdose of recreational
drugs or antidepressants
Known pregnancy  Pre-
existing liver disease or
pancreatitis  Known
metabolic disorder
predisposing to
hepatotoxicity
May not be best choice in
• acute or prior brain
injury
• known mood./behaviour
disorder
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3. Refractory Status (30-90mins):
Requires general anaesthesia with one of the following, titrated to
effect. Anaesthesia should be continued for 12-24 hrs after last clinical
or electrographic seizure, then dose tapered.
Propofol (1-2mg/kg bolus then 2-10mg/kg/hr). Risk of infusion
syndrome increases with duration of therapy
Midazolam (0.1-0.2mg/kg bolus, then 0.05-0.5mg/kg/hr)
Thiopental sodium (3-5mg/kg bolus then 3-5mg/kg/hour). After 2-3
days infusion rate needs reduction as fat stores are saturated.

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Neurology advice should always be sought for on-going management in
adults.
Send blood for pyridoxine (vitamin B6) level and give Pyridoxine 50mg
iv (as Pabrinex) if not already given.
At the least, intermittent EEG monitoring is necessary for refractory
status.

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SE (Treatment)
 Once fits controlled consider maintenance therapy.
 Monitor carefully for drug related respiratory depression.
 Intubation, ventilation and administration of sodium
pentothal infusion should only be performed in a centre
with trained anaesthetists and ICU.
 Attempt to control seizures and stabilise the patient
before referral
Refer if 1). failure to control seizures within 1 hour, 2.
where the primary cause is unknown, or if the primary
cause itself requires referral

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SE (Treatment)
C. Other Modalities of SE management
Intravenous fluid
• IV Dextrose 5% in sodium chloride 0.9% (DNS)
• Avoid overhydration-keep fluid volume at maintenance.
• Maintain normoglycaemia and electrolytes within the
normal range.

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SE (Treatment)
Cerebral oedema
• Treat when clinically suspected/proven.
• If the patient has a serum osmolality < 320
• mannitol, IV, 250 mg/kg administered over 30–60
minutes
Cerebral oedema with associated space occupying
lesion
• dexamethasone, IV, 0.5 mg/kg 12 hourly

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 The End
Thank You

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