Status epilepticus

DEFINITION: a seizure or series of seizures lasting more than 30 minutes without regaining full consciousness in between. Emergency treatment should commence after 5 minutes.

CONVULSIVE STATUS EPILEPTICUS is the most severe type of status. It has a mortality of 20%

Pathogenesis

Causes:

  • AED withdrawal
  • Trauma
  • Tumour
  • Cerebrovascular disease
  • CNS or systemic Infection
  • Metabolic disturbance
    • Hyponatraeamia
    • Hypocalcaemia
    • Hypoglycaemia
  • Alcohol intoxication

GENERAL CONSIDERATIONS:

  • CSE is an emergency
  • Prolonged CSE causes severe neuronal damage even if the convulsions stop (i.e. if the EEG shows ongoing epileptiform activity)
  • The longer CSE continues, the more refractory it is to treatment

Management

GENERAL MEASURES

  • Secure the airway if possible
  • Attach monitoring
    • BP
    • ECG
    • Oximetry
  • Give 100% O2
  • Protect the patient’s head
  • Obtain IV access
  • Bloods to send off
    • Glucose
    • Lactate, pH, WCC
    • Electrolytes
    • Thyroid hormones
    • AED level
  • Correct abnormalities as per, especially consider
    • 10ml Pabrinex (Thiamine)
    • 50% dextrose

IMMEDIATE MANAGEMENT

  • Slowly IV lorazepam 4mg for adults
    • 1mg/Kg for children
  • If I don’t have lorazepam
    • IV diazepam 20mg for adult
      • 5mg/Kg for child
    • If I don’t have IV access
      • Buccal midazolam 10mg in adults
        • 25mg/Kg, same for IM route

IF SEIZURES PERSIST AFTER 5 MINUTES

  • IV phenytoin 20mg/Kg @ 50mg/minute
    • Take their weight/2.5 à dose time

IF SEIZURES PERSIST

  • IV phenobarbitone 10mg/Kg @ 100mg/min

IF SEIZURES PERSIST à ITU FOR INTUBATION

  • IV propofol
    • Loading dose: 2mg/Kg
    • Continuous infusion: 10mg/Kg/hour
    • Stop when you see burst suppression on the EEG
  • Alternative if thiopental
  • Maintain AEDs