Status Epilepticus.

  • Status Epilepticus is a prolonged seizure that is either convulsive or non-convulsive which lasts greater than 15-30 minutes.

 ETIOLOGY/ PATHOGENESIS

  • May either be idiopathic and of generalized onset or secondary to bilateral spread from focal epileptogenic brain area.
  • The first manifestation of epilepsy in 10% of cases.
  • Specific cause or precipitating factor identified in 50-65% of cases: metabolic abnormalities, stroke, tumor, infection, hypoxia, drug abuse.
  • Mortality is 30%, usually related to underlying cause.

PERTINENT HISTORICAL FINDINGS/ CLINICAL SYMPTOMS

  • Convulsive form is a medical emergency that requires appropriate emergent treatment to avoid systemic and neurologic complications.
  • Non-convulsive presents as a new onset, in the middle aged or elderly. Abrupt onset with fluctuating confusional state that lasts from days to weeks

PERTINENT PHYSICAL EXAM FINDINGS

  • Convulsive form: generalized or focal seizure activity
  • Non-convulsive form: confusion, delirium, bizarre behavior, inappropriate affect, paranoia, delusions, catatonia, memory loss, mood changes.
  • Possible focal neurologic signs indicating mass lesion.
  • Changes in respiration, pulse, blood pressure, and possible temperature.
  • Further physical findings dependent on underlying cause.

DIFFERENTIAL DIAGNOSIS

  • Metabolic or toxic encephalopathy
  • Electrolyte imbalance
  • Delirium
  • Dementia
  • Infection
  • Tumor/ mass
  • Psychosis

DIAGNOSTIC EVALUATION

  • Antiepileptic drug levels
  • Complete blood count
  • Routine chemistries to include glucose levels
  • Brain imaging
  • ECG
  • Lumbar puncture if indicated

MEDICAL MANAGEMENT

See Emergency Management

SURGICAL MANAGEMENT (when applicable)

Not applicable

EMERGENCY MANAGEMENT (when applicable)

  • Protocol and Timetable for Treating Status Eplilepticus. See Table
TIME (MIN) ACTION
0-5 Give O2, ABC’s, obtain IV access; begin ECG monitoring; draw blood for chemistries-7, Mg, Ca, CBC, AED levels, ABG; toxicology screen
6-10 Thiamine 100mg IV; 50ml of D50 IV unless adequate glucose level known

Lorazepam 4mg IV/ 2min; repeat once in 8-10 min as needed OR

Diazepam 10mg IV/ 2 min; repeat once in 3-5 min as needed

10-20 If status persists or if used Diazepam, begin fosphenytoin 20 mg/kg IV at 150 mg/min, with blood pressure and ECG monitoring.
20-30 If status continues, give additional 5 mg of fosphenytoin 2 times, totaling  30 mg/kg
30 If status contiues, intubate and give one of the following with EEG monitoring:

  • Pentobarbital 2-10 mg/kg slow bolus, then .5-3 mg/kg.hr
  • Midazolam continuous infusion, .2 mg/kg slow bolus, then 0.1 -2.0 mg/kg/hr OR
  • Propofol continuous infusion, 1-5 mg/kg bolus over 5 min, then 2-4 mg/kg/hr

Adapted from: Cecil Textbook of Medicine: Chapter 434 The Epilepsies. Pg 2268.

PATIENT EDUCATION/ MAINTENANCE – PREVENTION

  • Stress importance of medication regiments and regular follow-up with treating physician.

Status1

Dr. Zachary Lahlou

One thought on “Status Epilepticus.

  1. Pingback: Status Epilepticus. | Dr. Zachary Lahlou

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