Neurology Book

http://www.fpnotebook.com/

Status EpilepticusAka: Seizure Emergency Management

Advertisement

  1. See Also
    1. Seizure
    2. Seizure Evaluation
  2. Epidemiology
    1. Prevalence: 152,000 cases per year in United States
    2. Age (Bimodal distribution)
      1. Adults: Highest Incidence after age 60 years
      2. Children: Highest Incidence under age 1 year
  3. Definition
    1. Continuous Seizure activity longer than 30 minutes or
    2. Two or more sequential Seizures
      1. No recovery of consciousness between Seizures
  4. Causes
    1. Poor medication compliance
    2. Alcohol Withdrawal
    3. Intracranial Infection
    4. Cerebral Neoplasm
    5. Metabolic disorder
    6. Drug overdose
  5. Differential Diagnosis
    1. See Altered Level of Consciousness
  6. Signs
    1. See definition above
    2. Witnessed persistent Seizure
    3. Consciousness not regained within 5 minutes of Seizure
  7. Labs
    1. Chemistry panel (Chem 8)
    2. Antiepileptic drug levels
    3. Urine Tox Screen
    4. Complete Blood Count
  8. Diagnostics
    1. Head CT
    2. Lumbar Puncture
    3. Electroencephalogram (EEG)
  9. Management: Initial
    1. See ABC Management
    2. Control airway
      1. Nasal Airway
      2. Consider intubation
    3. Obtain IV Access with normal saline to keep open
    4. Administer oxygen
    5. Monitor vital signs closely
      1. Especially temperature
      2. Telemetry
    6. Empiric antidotes
      1. D50W 50 ml IV (Adult dosing)
      2. Thiamine 100 mg IV or IM
    7. Anticonvulsants
      1. First
        1. Lorazepam 0.1 to 0.15 mg/kg IV (2 mg/minute)
      2. Next (if refractory)
        1. Fosphenytoin (Cerebyx) 18 mg/kg IV (150 mg/minute)
      3. Next (if refractory)
        1. Additional Fosphenytoin (Cerebyx) 7 mg/kg IV
  10. Management: Persistent Seizure at 30 minutes
    1. Intubate and ventilate
    2. Foley Catheter
    3. Electroencephalogram (EEG)
    4. Follow temperature closely
    5. Phenobarbital load 20 mg/kg IV (100 mg/min)
  11. Management: Persistent Seizure at 60 minutes
    1. General
      1. Dosages below titrated based on EEG
      2. Infusion slowed every 4-6 hours to check EEG status
      3. Requires full life support (coma state)
      4. May require Blood Pressure support
    2. Pentobarbital 5 mg/kg IV then 1 mg/kg/hour or
    3. Midazolam 0.2 mg/kg IV then 0.75 to 10 mg/kg/hour or
    4. Propofol 1 to 2 mg/kg load, then 2-10 mg/kg/hour
  12. Prognosis
    1. Mortality
      1. Overall: 22%
      2. Children: 3%
      3. Adults: 26%
      4. Elderly: 38%
      5. DeLorenzo (1996) Neurology 46:1026
    2. Morbidity
      1. High Incidence of neurologic sequelae
  13. References
    1. (1993) JAMA 270:854
    2. Lowenstein (1998) N Engl J Med 338:970
    3. Sirven (2003) Am Fam Physician 68(3):469

Navigation Tree