Status epilepticus: Difference between revisions

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###PE = phenytoin equivalents (1.5 mg fosphenytoin = 1 mg phenytoin)
###PE = phenytoin equivalents (1.5 mg fosphenytoin = 1 mg phenytoin)
###20 mg/kg phenytoin is given slower at 50 mg/min
###20 mg/kg phenytoin is given slower at 50 mg/min
## Thiamine 100mg IV along with 50ml D50IV.
## Thiamine 100mg IV along with 50ml D50IV
## Consider 5 g of pyridoxine (Vitamin B6), up to 20 g, for TB patients with suspected INH toxicity (urban hospital, especially in international medicine)<ref>Weisiger RA. Isoniazid Toxicity Treatment and Management - Supportive and Pharmacologic Therapy. Updated Dec 16, 2014. http://emedicine.medscape.com/article/180554-treatment#d8</ref>
#Briefly familiarize patient H+P to help guide diagnostic causes
#Briefly familiarize patient H+P to help guide diagnostic causes
##PMHx: Sz History? (get AED levels/home dosages), CNS insults?
##PMHx: Sz History? (get AED levels/home dosages), CNS insults?

Revision as of 01:02, 25 August 2015

Background

Definition

  • Status epilepticus is the persistence of seizure beyond 20 minutes. [1]
    • Functionally presume people to be in status if clinically seizing beyond 5 minutes[2]
      • Convulsive - meaning obvious clinical signs of seizure activity –tonic clonic/myoclonic/tonic
      • Non-convulsive - meaning no obvious signs of activity but decreased level of consciousness
    • NCSE (Non consulsive status) is a critical and relevant consideration. Up to 50% of patients with generalized tonic-clonic seizures will have NCSE after convulsions have subsided.


  • Seizures are abnormal neuronal activity with various neurological sequale.
    • Further defined by whether they involve 1 hemisphere (partial) or both hemispheres (generalized). While generalized seizures surely cause an alteration in mental status, seizures involving one hemisphere (partial) may further be subdivided by whether they maintain baseline mental status (simple) or an alteration (complex).
  • Epilepsy is defined a 2 or more epileptic seizures that occur unprovoked by any identifiable cause. This include all seizure events with the exception of febrile or neonatal seizures.
    • Further subclassified into cryptogenic (meaning unknown cause) or symptomatic (meaning associated with previous CNS insult).
      • Symptomatic seizures further subdefined as acute or remote (depending on if > or < 1 week after CNS insult)
  • Seizure type and associated EEG findings are at core of determining risk of recurrence and indication for antiepileptic therapy. Follow the “seizure” link (pending Jan 2014) for more information on the non-acute general treatment of seizures.

Management of acute status epilepticus

Overview

  • The general theme of seizure treatment is to
  1. Address immediate concerns (ABC’s) (primarily referring to airway/breathing)
    1. Constantly return to evaluate this for the duration of seizure episode
      1. continuously monitor O2 saturations via pulse oximetry
      2. periodic blood gases to evaluate for CO2 retention and lactic acidosis (q10-15mins- up to clinical judgement).
  2. Manage the seizure activity with medications along with investigation/correction of causes.
    1. Treat quickly; Do not hold medications. Treatment initiated in first 30 minutes has 80% response. Drops to 40% around two hours
      1. Medication regimes include a benzodiazepine to terminate seizure in immediate term and an anti-epileptic drug (AED) to continue longer term neuronal suppression. Continued seizure activity is treated by additive AED’s and/or sedating medications.
      2. Very often phenytoin is used for AED (Cost and plethora of studies) however alternatives exist Leveteriacetam, lacosamide, valproate with lesser side effect profile. You may refer to pharmacy for assistance with typical protocol, otherwise phenytoin is acceptable and can always be changed to another AED later.

Take a Stepwise Approach: Timeline

0-5 minutes

  1. Is this patient still seizing ? (look for return of consciousness) or if on EEG look to EEG (Reading EEGs link to come).
    1. If this is first episode, may await seizure to break however ready materials to be given should seizure persist greater than 5 minutes
  2. Protect patient
    1. turn on side prn for airway protection if vomitting to attenuate aspiration events. Remove any obvious dangerous material that may hurt the patient.
    2. DO NOT, try to limit patient movement by holding extremities down. DO NOT place bite block (risk of occluding airway).
  3. Obtain Diagnostic labs (CBC, CEM 10, LFT, coagulation, AED levels (If indicated: assess if therapeutic), ECG, troponins, toxicology screen, pregnancy test (preparation for possible CT), blood gas, continuous SaO2, BP and continuous ECG.
  4. Ready medications to be given if seizure persists > 5 minutes
    1. lorazepam (0.1mg/kg max given in 2-4 mg aliquots )
    2. AED loading agent (Fosphenytoin 20 PE/kg, at 150 mg/min)
      1. PE = phenytoin equivalents (1.5 mg fosphenytoin = 1 mg phenytoin)
      2. 20 mg/kg phenytoin is given slower at 50 mg/min
    3. Thiamine 100mg IV along with 50ml D50IV
    4. Consider 5 g of pyridoxine (Vitamin B6), up to 20 g, for TB patients with suspected INH toxicity (urban hospital, especially in international medicine)[3]
  5. Briefly familiarize patient H+P to help guide diagnostic causes
    1. PMHx: Sz History? (get AED levels/home dosages), CNS insults?
      1. description of previous seizures semiology (if applicable) – jerking/automatisms/gaze deviation
    2. Medications: anything that reduces seizure threshold?
    3. Physical Exam: Neuro evaluation
      1. while in convulsive status patient is obviously seizing and one should continue timeline for acute treatment. The neuro exam is primarily focused on identifying 1. Neuro signs to help localize seizure focus 2.identifying NCSE; focusing on recognizing an improvement of wakefulness/mental status.
        1. No improvement in wakefulness >20 minutes or continued AMS > 30-60 minutes prompts concern for NCSE and requires 24-48hr cEEG

6-10 minutes (seizure persists)

  1. Administer thiamine 100mg IV along with 50ml D50IV (empirically for possible hypoglycemia)
    1. May forego if hypoglycemia ruled out with recent CEM panel.
  2. Administer the 2-4mg lorazepam aliquot over 2 minutes.
    1. Repeat 1x (max dose 0.1mg/kg) if seizure continues another 5 minutes.
    2. If no IV access available. Diazepam may be given rectally (20mg PR) or Midazolam (10mg intrabucally/intranasally).

10-20 minutes

  1. Admin AED loading agent (Fosphenytoin 20 PE/kg). MAX INFUSION RATE 150mg/min
    1. Phenytoin associated with hypotension. Fosphenytoin use attenuates some of this risk however still significant. Administer with frequent BP checks and ECG monitoring.
      1. Continue AED maintenance with target phenytoin level 2-3 G/mL after seizure subsides (typically qd checks). Defer to neurology for long term AED management.
    2. If seizure persists may rebolus 1x with additional Fosphenyoitn 10 PE/kg bolus.
  2. OTHER OPTION
    1. if patient on AED at home, may reload with home medication: Some examples below
      1. IV valproate: 20mg/kg over 10 minutes. May re bolus (same dose) 1x if seizure persists > 5 minutes following
      2. IV keppra 1000-4000mg IV
  3. Reassess ABC status
  4. Make arrangements for possible ICU transfer ( If applicable - as next step is intubation).

20-60 minutes (refractory status epilepticus

  1. Intubate for airway protection (As we will definitively sedate to the point of respiratory compromise)
  2. Place arterial line (Continuous BP monitoring with propofol infusion)
  3. Medications (May use propofol as pressure tolerates, otherwise midazolam; Typically start with propofol since may regain neuro exam faster, and add midazolam).
    1. IV propofol (causes hypotension)
      1. 1mg/kg bolus with continued boluses (same dose) every 3-5 minutes until seizures stop (As BP tolerates).
      2. May place on cIV infusion 1-15 mg/kg/h (Do not exceed >5mg/kg/h in 24 hrs)
    2. IV midazolam (less hypotension, longer sedation than propofol)
      1. 0.2mg/kg bolus with repeat boluses (Same dose) every 5 minutes until seizures stop (max dose 2mg/kg)
      2. May place on cIV 0.05-2.0 mg/kg/h (up to 200mg/h for 70kg patient).

> 60 minutes

  1. Place in pentobarbital coma
    1. 5 mg/kg up to 50mg/min. Repeat boluses (same dose) until seizure stop.
    2. cIV 1mg/kg/h titrated to suppression on cEEG.

External Links

EM Nerd Adventure of dancing men

See Also

References

  1. Brodie MJ Status epilepticus in adults. Lancet. 1990 Sep 1; 336(8714):551-2.
  2. Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med. 1998; 338:970-976
  3. Weisiger RA. Isoniazid Toxicity Treatment and Management - Supportive and Pharmacologic Therapy. Updated Dec 16, 2014. http://emedicine.medscape.com/article/180554-treatment#d8
  • Brophy GM. Guidelines for the Evaluation and Management of Status Epilepticus. J Neurocrit Care. 2012, Apr;17(1):3-23.