Status epilepticus: Difference between revisions

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==Background==
==Background==
*Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments.<ref>Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9</ref><ref>Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8</ref> (Previous definitions used a 30-minute time limit)<ref>Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.</ref>
*Overall mortality is high (22%)<ref name="Martindale">Martindale JL, Goldstein JN, Pallin DJ. Emergency department seizure epidemiology. Emerg Med Clin North Am. 2011 Feb;29(1):15-27.</ref>
==Clinical Features==
==Clinical Features==
*Seizure > 20 minutes. <ref>Brodie MJ Status epilepticus in adults. Lancet. 1990 Sep 1; 336(8714):551-2.</ref>
*Seizure > 20 minutes. <ref>Brodie MJ. Status epilepticus in adults. Lancet. 1990 Sep 1; 336(8714):551-2.</ref>
*Presume status in current seizure > 5 minutes<ref>Lowenstein DH, Alldredge BK.  Status epilepticus.  N Engl J Med. 1998; 338:970-976</ref>
*Presume status in current seizure > 5 minutes<ref>Lowenstein DH, Alldredge BK.  Status epilepticus.  N Engl J Med. 1998; 338:970-976</ref>


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{{Seizure DDX}}
{{Seizure DDX}}


==Diagnosis==
==Evaluation==
*Clinical diagnosis
*Clinical diagnosis


==ED Management==
==Managment==
*Consider secondary causes of seizure (e.g. [[hyponatremia]], hypoglycemia, INH overdose, [[ecclampsia]])
{{Seizure actively seizing management}}
*Consider EEG to rule-out nonconvulsive status
*Consider prophylactic intubation
*Consider anesthesia c/s for inhaled anesthetics in OR for refractory status epilepticus<ref>Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.</ref>
*Meds
**First-Line
***[[Lorazepam]] 2mg IV (up to 0.1mg/kg) OR [[diazepam]] 5-10mg IV (up to 0.15mg/kg); AND
***[[Phenytoin]] 20-30mg/kg at 50mg/min OR [[fosphenytoin]] 20-30mg/kg/PE at 150mg/min
****[[Phenytoin]]/[[fosphenytoin]] contraindicated in pts w/ 2nd or 3rd degree AV block
****[[Phenytoin]] may cause hypotension due to propylene glycol diluent
****[[Fosphenytoin]] may be given IM
**Refractory
***[[Valproic acid]] 20-40mg/kg at 5mg/kg/min OR
***[[Phenobarbital]] 20mg/kg at 50-75mg/min (be prepared to intubate) OR
***[[Propofol]] 2-5mg/kg, then infusion of 2-10mg/kg/hr OR
***[[Midazolam]] 0.2mg/kg then inusion of 0.05-2mg/kg/hr OR
***[[Ketamine]] 1.5mg/kg then 0.01-0.05mg/kg/hr
****Contraindicated in pts w/ intracranial masses
 
==Neuro ICU Management==
*Address immediate concerns (ABC’s) (primarily referring to airway/breathing)
**Constantly return to evaluate this for the duration of seizure episode
***continuously monitor O2 saturations  via pulse oximetry
***periodic blood gases to evaluate for CO2 retention and lactic acidosis (q10-15mins- up to clinical judgement).
*Manage the seizure activity with medications along with investigation/correction of causes.
**Treat quickly; Do not hold medications. Treatment initiated in first 30 minutes has 80% response. Drops to 40% around two hours
***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.
***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====
*Is this patient still seizing ? (look for return of consciousness) or if on EEG look to EEG (Reading EEGs link to come).
**If this is first episode, may await seizure to break however ready materials to be given should seizure persist greater than 5 minutes
*Protect patient
**turn on side prn for airway protection if vomitting to attenuate aspiration events. Remove any obvious dangerous material that may hurt the patient.
**DO NOT, try to limit patient movement by holding extremities down. DO NOT place bite block (risk of occluding airway).
*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.
*Ready medications to be given if seizure persists > 5 minutes
**lorazepam (0.1mg/kg max given in 2-4 mg aliquots )
** AED loading agent  (Fosphenytoin 20 PE/kg, at 150 mg/min)
***PE = phenytoin equivalents (1.5 mg fosphenytoin = 1 mg phenytoin)
***20 mg/kg phenytoin is given slower at 50 mg/min
** Thiamine 100mg IV along with 50ml D50IV
** Consider 5 g of pyridoxine (Vitamin B6) over 5-10 min, repeat up to total 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><ref>Vasu T and Saluja J. INH Induced Status Epilepticus: Response to Pyridoxine. Indian J Chest Dis Allied Sci 2006; 48: 205-206.</ref>
*Briefly familiarize patient H+P to help guide diagnostic causes
**PMHx: Sz History? (get AED levels/home dosages), CNS insults?
***description of previous seizures semiology (if applicable) – jerking/automatisms/gaze deviation
**Medications: anything that reduces seizure threshold?
**Physical Exam: Neuro evaluation
***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.
****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)====
*Administer thiamine 100mg IV along with 50ml D50IV (empirically for possible hypoglycemia)
**May forego if hypoglycemia ruled out with recent CEM panel.
*Administer the 2-4mg lorazepam aliquot over 2 minutes.
**Repeat 1x (max dose 0.1mg/kg) if seizure continues another 5 minutes.
**If no IV access available. Diazepam may be given rectally (20mg PR) or Midazolam (10mg intrabucally/intranasally).
====10-20 minutes ====
*Admin AED loading agent (Fosphenytoin 20 PE/kg). MAX INFUSION RATE 150mg/min
**Phenytoin associated with hypotension. Fosphenytoin use attenuates some of this risk however still significant. Administer with frequent BP checks and ECG monitoring.
***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.
**If seizure persists may rebolus 1x with additional Fosphenyoitn 10 PE/kg bolus.
*OTHER OPTION
**if patient on AED at home, may reload with home medication: Some examples below
***IV valproate: 20mg/kg over 10 minutes. May re bolus (same dose) 1x if seizure persists > 5 minutes following
***IV keppra 1000-4000mg IV
*Reassess ABC status
*Make arrangements for possible ICU transfer ( If applicable - as next step is intubation).
 
====20-60 minutes (refractory status epilepticus)====
*Intubate for airway protection (As we will definitively sedate to the point of respiratory compromise)
*Place arterial line (Continuous BP monitoring with propofol infusion)
*Medications (May use propofol as pressure tolerates, otherwise midazolam; Typically start with propofol since may regain neuro exam faster, and add midazolam).
**IV propofol (causes hypotension)
*** 1mg/kg bolus with continued boluses (same dose) every 3-5 minutes until seizures stop (As BP tolerates).
***May place on cIV infusion 1-15 mg/kg/h (Do not exceed >5mg/kg/h in 24 hrs)
**IV midazolam (less hypotension, longer sedation than propofol)
***0.2mg/kg bolus with repeat boluses  (Same dose) every 5 minutes until seizures stop (max dose 2mg/kg)
***May place on cIV 0.05-2.0 mg/kg/h (up to 200mg/h for 70kg patient).
 
====> 60 minutes ====
*Place in pentobarbital coma
**5 mg/kg up to 50mg/min. Repeat boluses (same dose) until seizure stop.
**cIV 1mg/kg/h  titrated to suppression on cEEG.


==Disposition==
==Disposition==
*Admit
*Admit to ICU or intermediate level of monitored care depending on etiology, treatments and respiratory status


==External Links==
==External Links==
EM Nerd [http://emnerd.com/adventure-dancing-men/ Adventure of dancing men]
*EM Nerd [http://emnerd.com/adventure-dancing-men/ Adventure of dancing men]


==See Also==
==See Also==
*[[Seizure]]
*[[Seizure]]
*[[Prehospital protocol pediatric seizure]]


==References==
==References==
<references/>
<references/>


[[Category:Neuro]]
[[Category:Neurology]]

Revision as of 01:39, 27 July 2016

Background

  • Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments.[1][2] (Previous definitions used a 30-minute time limit)[3]
  • Overall mortality is high (22%)[4]

Clinical Features

  • Seizure > 20 minutes. [5]
  • Presume status in current seizure > 5 minutes[6]

Differential Diagnosis

Seizure

Evaluation

  • Clinical diagnosis

Managment

Seizure Precautions

  • Protect patient from injury
    • If possible, place patient in left lateral position to reduce risk of aspiration
    • Do not place bite block!
  • Jaw thrust, a NPA and oxygen may be required
  • An IV line should be placed

Medications

  • Benzodiazepine (Initial treatment of choice)[7]
    • Midazolam IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg[8]
      • May also be given IN at 0.2 mg/kg, max 10 mg
      • OR buccal at 0.3 mg/kg, max 10 mg
    • Lorazepam IV 4 mg or 0.1 mg/kg; may repeat one dose[9]
    • Diazepam IV 0.15-0.2 mg/kg (up to 10 mg); may repeat one dose or PR 0.2-0.5 mg/kg (up to 20 mg) once [10]
  • Secondary medications
    • ESETT trial[11] compared second line antiseizure medications and they all are equally efficacious. Therefore may be best to use the one with least side effects [12] which is Levetiracetam
    • Levetiracetam IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred in pregnancy)[13]
    • Phenytoin IV 18 mg/kg at ≤ 50 mg/min (avoid in pregnancy)[14]
    • Fosphenytoin IV 20-30 mg/kg at 150 mg/min (may also be given IM)
      • Contraindicated in pts w/ 2nd or 3rd degree AV block
      • Avoid phenytoin or fosphenytoin in suspected toxicology case due to sodium channel blockade
    • Valproic acid IV 20-40 mg/kg at 5 mg/kg/min, max 3000 mg (avoid in pregnancy)[15]
  • Refractory medications
    • Propofol 2-5mg/kg, then infusion of 2-10mg/kg/hr OR
    • Midazolam 0.2mg/kg, then infusion of 0.05-2mg/kg/hr OR
    • Ketamine loading dose 0.5 to 3 mg/kg, followed by infusion of 0.3 to 4 mg/kg/hr[16]
    • Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV[17]
    • Phenobarbital IV 15-20 mg/kg at 50-75 mg/min[18]
      • Then continuous infusion at 0.5-4.0 mg/kg/hr
      • Dose adjusted to suppression-burst pattern on continuous EEG
    • Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)[19]
  • Others

Other Considerations

Disposition

  • Admit to ICU or intermediate level of monitored care depending on etiology, treatments and respiratory status

External Links

See Also

References

  1. Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9
  2. Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8
  3. Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.
  4. Martindale JL, Goldstein JN, Pallin DJ. Emergency department seizure epidemiology. Emerg Med Clin North Am. 2011 Feb;29(1):15-27.
  5. Brodie MJ. Status epilepticus in adults. Lancet. 1990 Sep 1; 336(8714):551-2.
  6. Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med. 1998; 338:970-976
  7. Glauser T, 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.
  8. McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582
  9. 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. doi:10.5698/1535-7597-16.1.48
  10. 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. doi:10.5698/1535-7597-16.1.48
  11. Kapur J, Elm J, Chamberlain J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103-2113. doi:10.1056/NEJMoa1905795
  12. PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
  13. Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
  14. Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
  15. Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
  16. Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
  17. Legros B et al. Intravenous lacosamide in refractory seizure clusters and status epilepticus: comparison of 200 and 400 mg loading doses. Neurocrit Care. 2014 Jun;20(3):484-8.
  18. Pugin D et al. Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study. Critical Care 2014. DOI: 10.1186/cc13883.
  19. Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.