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Status Epilepticus
Aka: Status Epilepticus, Seizure Emergency Management
- See Also
- Seizure
- Seizure Evaluation
- Epidemiology
- Prevalence: 152,000 cases per year in United States
- Age (Bimodal distribution)
- Adults: Highest Incidence after age 60 years
- Children: Highest Incidence under age 1 year
- Definition
- Continuous Seizure activity longer than 30 minutes or
- Two or more sequential Seizures
- No recovery of consciousness between Seizures
- Causes
- Poor medication compliance
- Alcohol Withdrawal
- Intracranial Infection
- Cerebral Neoplasm
- Metabolic disorder
- Drug overdose
- Differential Diagnosis
- See Altered Level of Consciousness
- Signs
- See definition above
- Witnessed persistent Seizure
- Consciousness not regained within 5 minutes of Seizure
- Labs
- Basic Chemistry panel (Basic Metabolic panel, Chem 8)
- Hepatic panel
- Magnesium
- Glucose
- Antiepileptic drug levels
- Urine Tox Screen
- Complete Blood Count
- Diagnostics
- Head CT
- Lumbar Puncture
- Electroencephalogram (EEG)
- Management: Initial
- See ABC Management
- Control airway
- Nasal Airway
- Consider intubation
- Obtain IV Access with normal saline to keep open
- Administer oxygen
- Monitor vital signs closely
- Especially temperature
- Telemetry
- Empiric antidotes
- D50W 50 ml IV (Adult dosing)
- Thiamine 100 mg IV or IM
- Management: Anticonvulsants
- First
- Lorazepam 0.1 to 0.15 mg/kg IV (2 mg/minute)
- Obtain vital signs and EKG
- Next (if refractory after 5 minutes)
- Phenytoin (Dilantin) 20 mg/kg IV
- May repeat once with Phenytoin 5-10 mg/kg IV
- Maintenance with Phenytoin 50 mg/min
- Next (if refractory after 30 minutes)
- Phenobarbital 20 mg/kg IV
- May repeat once with Phenobarbital 5-10 mg/kg IV
- Maintenance with Phenobarbital 50 mg/min
- Next (if refractory after 60 minutes)
- Preparation
- Intubate
- Pressor support (required for next set of medictions)
- Choose one medication for Sedation
- Propofol 5 mg/kg IV load, then 30-100 mcg/kg/min IV maintenance OR
- Midazolam 0.2 mg/kg IV load, then 75-100 mcg/kg/min IV maintenance
- Management: Persistent Seizure at 30 minutes
- Intubate and ventilate
- Foley Catheter
- Electroencephalogram (EEG)
- Follow temperature closely
- Phenobarbital load 20 mg/kg IV (100 mg/min)
- Management: Persistent Seizure at 60 minutes
- General
- Dosages below titrated based on EEG
- Infusion slowed every 4-6 hours to check EEG status
- Requires full life support (coma state)
- May require Blood Pressure support
- Pentobarbital 5 mg/kg IV then 1 mg/kg/hour or
- Midazolam 0.2 mg/kg IV then 0.75 to 10 mg/kg/hour or
- Propofol 1 to 2 mg/kg load, then 2-10 mg/kg/hour
- Prognosis
- Mortality
- Overall: 22%
- Children: 3%
- Adults: 26%
- Elderly: 38%
- DeLorenzo (1996) Neurology 46:1026-35
- Morbidity
- High Incidence of neurologic sequelae
- References
- (1993) JAMA 270:854-9
- Lowenstein (1998) N Engl J Med 338:970-6
- Sirven (2003) Am Fam Physician 68(3):469-76