Status epilepticus
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Background
Clinical Features
Differential Diagnosis
Seizure
- Epileptic seizure
- First-time seizure
- Seizure with known seizure disorder
- Status epilepticus
- Temporal lobe epilepsy
- Non-compliance with anti-epileptic medications
- Hyponatremia
- INH toxicity
- Non-epileptic seizure
- Meningitis
- Encephalitis
- Brain abscess
- Intracranial hemorrhage
- Alcohol withdrawal
- Benzodiazepine withdrawal
- Barbiturate withdrawal
- Baclofen withdrawal
- Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia, hepatic failure, uremia
- Eclampsia
- Neurocysticercosis
- Posterior reversible encephalopathy syndrome
- Impact seizure (head trauma)
- Acute hydrocephalus
- Arteriovenous malformation
- Seizure with VP shunt
- Toxic ingestion (amphetamines, anticholinergics, cocaine, INH, organophosphates, TCA, salicylates, lithium, phenothiazines, bupropion, camphor, clozapine, cyclosporine, fluoroquinolones, imipenem, lead, lidocaine, metronidazole, synthetic cannabinoids, theophylline, Starfruit)
- Psychogenic nonepileptic seizure (pseudoseizure)
- Intracranial mass
- Syncope
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
- Post-hypoxic myoclonus (Status myoclonicus)
Diagnosis
- Clinical diagnosis
Active Seizure 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)[3]
- Midazolam IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg[4]
- 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[5]
- 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 [6]
- Midazolam IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg[4]
- Secondary medications
- ESETT trial[7] compared second line antiseizure medications and they all are equally efficacious. Therefore may be best to use the one with least side effects [8] which is Levetiracetam
- Levetiracetam IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred in pregnancy)[9]
- Phenytoin IV 18 mg/kg at ≤ 50 mg/min (avoid in pregnancy)[10]
- 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)[11]
- 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[12]
- Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV[13]
- Phenobarbital IV 15-20 mg/kg at 50-75 mg/min[14]
- 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)[15]
- Others
- Carbamazepine 8 mg/kg oral suspension, single oral load
- Gabapentin 900 mg/day oral at 300 mg tid for 3 days
- Lamotrigine 6.5 mg/kg single oral load
Other Considerations
- Secondary causes of seizure (e.g. hyponatremia, hypoglycemia, INH toxicity, ecclampsia)
- Nonconvulsive seizures or status epilepticus - get EEG
Disposition
- Admit to ICU or intermediate level of monitored care depending on etiology, treatments and respiratory status
External Links
EM Nerd Adventure of dancing men
See Also
References
- ↑ Brodie MJ Status epilepticus in adults. Lancet. 1990 Sep 1; 336(8714):551-2.
- ↑ Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med. 1998; 338:970-976
- ↑ 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.
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
- ↑ 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.
- ↑ 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.
- ↑ Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.