- Status Epilepticus is a prolonged seizure that is either convulsive or non-convulsive which lasts greater than 15-30 minutes.
- 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.
- Metabolic or toxic encephalopathy
- Electrolyte imbalance
- Tumor/ mass
- Antiepileptic drug levels
- Complete blood count
- Routine chemistries to include glucose levels
- Brain imaging
- Lumbar puncture if indicated
See Emergency Management
SURGICAL MANAGEMENT (when applicable)
EMERGENCY MANAGEMENT (when applicable)
- Protocol and Timetable for Treating Status Eplilepticus. See Table
|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:
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.
Dr. Zachary Lahlou