Status epilepticus - NYSORA

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Status epilepticus

Learning objectives

  • Describe the overall mechanisms and common causes of status epilepticus
  • Describe the signs of status epilepticus
  • Prevent status epilepticus
  • Manage status epilepticus

Definition & mechanisms

  • Status epilepticus is defined as more than 30 minutes of either 1) continuous seizure activity or 2) two or more sequential seizures without full recovery of consciousness between seizures
  • Cerebral damage is more likely if the seizure is prolonged
  • There are lots of different types of seizures and not all of them involve obvious convulsive activity
  • Epilepsy can occur at any age but is commonly diagnosed in those aged below 20 or over 65 years
  • First stage is characterized by an increase in:
    • Cerebral metabolism
    • Blood flow
    • Glucose and lactate concentration
  • Compensatory mechanisms:
    • Massive catecholamine release
    • Raised cardiac output
    • Hypertension
    • Increased central venous pressure
  • After 30-60 min, compensatory mechanisms fail:

Etiology

  • Acute
  • Chronic
    • Inheritance tendency
    • Low concentration of anti-epileptic drugs
    • Structural changes to the brain (trauma) or space occypying lesions (tumor, stroke)
    • Alcohol misuse (adults)
    • Idiopathic

Signs & symptoms

Status epilepticus can present in several forms: 

  • Convulsive: unresponsiveness and tonic, clonic, or tonic-clonic movements of the extremities
  • Non-convulsive: prolonged seizure activity evidenced by epileptiform discharges on EEG, change in behavior or cognition in some patients
  • Electrographic: commonly used for comatose patients who show electrographic evidence of prolonged seizure activity

Diagnosis

  • Based on history and clinical examination
  • Often present either actively convulsing or minimal time between clustered seizures

Prevention

  • Seizure detection based on EEG and immediate treatment
  • In patients with a history of well-controlled epilepsy, avoid disruption of antiepileptic medication perioperatively

Management

status epilepticus, management, seizure, monitor, oxygen, intubation, blood glucose, thiamine, electrolytes, hematology, toxicology, anticonvulsant, midazolam, lorazepam, diazepam phenobarbital, fosphenytoin, valproic acid, levetiracetam, thiopental, pentobarbital, propofol, EEG

 

Status epilepticus medications: Overview

Rescue benzodiazepines

MedicationDose range (max dose)Comments
IV lorazepam0.05-0.1 mg/kg/dose (2-4 mg)May repeat dose once
Rectal diazepam0.2-0.5 mg/kg (20 mg)Age 6 months - 5 years: 0.5 mg/kg
Age 6-12 years: 0.3 mg/kg
Age 12+ years: 0.2 mg/kg
Nasal midazolam0.2-0.3 mg/kg (5-10 mg)<40 kg: 0.2-0.3 mg/kg
>40 kg: give 10 mg (max dose), half the dose in each nostril
IM midazolam0.2-0.3 mg/kg (5-10 mg)<13 kg: 0.2-0.3 mg/kg
13-40 kg: give 5 mg
>40 kg: give 10 mg (max dose)
IV diazepam0.15-0.3 mg/kg (10mg)Shorter duration compared to lorazepam
Higher risk for respiratory depression

Tier 2 medications

MedicationDose range (max dose)Comments
Fosphenytoin20 mg PE/kg (1500 mg)Drug levels quickly available for titration
Avoid if known generalized epilepsy or Dravet syndrome
Beware of hypotension and bradycardia
Tissue extravasation is potentially dangerous
Levetiracetam60 mg/kg (4500 mg)Also effective for myoclonic seizures
Valproic acid 40 mg/kg (3000 mg)Effective in juvenile myoclonic epilepsy, myoclonic status and absence status
Caution in patients with liver dysfunction and select metabolic diseases (e.g., POLG1)
Phenobarbital10-20 mg/kg (1000 mg)Drug of choice in newborns
Beware of hypotension and respiratory depression
May use in adults if previously used with status due to missed or held doses
Lacosamide5-10 mg/kg (400 mg)Caution with cardiac issues, can prolong PR interval
Use if previously used and status due to missed or held doses

Suggested reading

  • Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61.
  • Betjemann JP, Lowenstein DH. Status epilepticus in adults. Lancet Neurol. 2015;14(6):615-624.
  • Perks A, Cheema S, Mohanraj R. Anaesthesia and epilepsy. BJA: British Journal of Anaesthesia. 2012;108(4):562-71.

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