Status Epilepticus

Aka: Status Epilepticus, Seizure Emergency Management

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. Basic Chemistry panel (Basic Metabolic panel, Chem 8)
   2. Hepatic panel
   3. Magnesium
   4. Glucose
   5. Antiepileptic drug levels
   6. Urine Tox Screen
   7. 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
10. Management: Anticonvulsants
    1. First
       1. Lorazepam 0.1 to 0.15 mg/kg IV (2 mg/minute)
       2. Obtain vital signs and EKG
    2. Next (if refractory after 5 minutes)
       1. Phenytoin (Dilantin) 20 mg/kg IV
          1. May repeat once with Phenytoin 5-10 mg/kg IV
          2. Maintenance with Phenytoin 50 mg/min
    3. Next (if refractory after 30 minutes)
       1. Phenobarbital 20 mg/kg IV
          1. May repeat once with Phenobarbital 5-10 mg/kg IV
          2. Maintenance with Phenobarbital 50 mg/min
    4. Next (if refractory after 60 minutes)
       1. Preparation
          1. Intubate
          2. Pressor support (required for next set of medictions)
       2. Choose one medication for Sedation
          1. Propofol 5 mg/kg IV load, then 30-100 mcg/kg/min IV maintenance OR
          2. Midazolam 0.2 mg/kg IV load, then 75-100 mcg/kg/min IV maintenance
11. 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)
12. 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
13. Prognosis
    1. Mortality
       1. Overall: 22%
       2. Children: 3%
       3. Adults: 26%
       4. Elderly: 38%
       5. DeLorenzo (1996) Neurology 46:1026-35
    2. Morbidity
       1. High Incidence of neurologic sequelae
14. References
    1. (1993) JAMA 270:854-9
    2. Lowenstein (1998) N Engl J Med 338:970-6
    3. Sirven (2003) Am Fam Physician 68(3):469-76