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Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor
Status epilepticus is continuous or intermittent seizures for more than 5 minutes without recovery of consciousness.
Treatment for status epilepticus should be initiated in all patients with continuous seizure activity lasting more than 5 min. because seizures lasting for than 5 min is unlikely to terminate spontaneously and more likely to cause neuronal damage.
Definitions
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MANAGEMENT
The goal of the treatment is to control seizures within 60 min of presentation.
Address ABC
Airway & Breathing :
Maintain the patency of the airway. Suctioning to clear any vomitus, secretions.
Oropharyngeal or nasopharyngeal airway devices may be used to maintain patency of the airway.
Oxygen may be provided through nasal prongs or face mask.
Patient has to be intubated if the patency of the airway cannot be maintained or incase of prolonged seizures inorder to secure the airway.
Circulation
A large IV line should be established.
Collect samples for ABG, GRBS , Serum electrolyte levels ,CBC , Toxicology screen, Antiepileptic drug level.
Initiate drugs immediately.
ECG Monitoring
Check Sugars and correct if required.
First Line Agent
Benzodiazipines (Emergent Initial Antiepileptic Therapy)
Benzodiazepines are the first line agents used to control seizures temporarily.
Inj lorazepam 2-4 mg (upto 0.1mg/kg) or diazepam 5 – 10 mg upto 0.15mg/kg can be repeated in 5 -10 minutes or Inj. Midazolam IM are established as efficacious at stopping seizures.
Lorazepam has slower onset of action 3minutes where as diazepam is 2 minutes, but lorazepam has a longer duration of action (12 -24 hrs) whereas lorazepam has shorter duration of action (15 -60 minutes), and is associated with fewer seizure recurrence. Thus lorazepam is considered as initial agent of choice.
Intramuscular midazolam has superior effectiveness compared with IV lorazepam in adults with convulsive status epilepticus.
In children's with difficult IV access rectal diazepam or intramuscular /intranasal / buccal midazolam are probably effective in controlling seizures lasting > 5 minutes. Studies have shown that IM/intranasal/ buccal midazolam is more effective than diazepam.
Second Line Agent (Control AED Therapy)
Phenytoin/ Fosphenytoin
Phenytoin is the most commonly used antiepileptic drug.
IV Phenytoin 20 -30 mg/kg at 50 mg/min or IV Fosphenytoin 20 -30 mg/kg PE at 150mg/min.
Rapid infusion of phenytoin can cause bradycardia, arrythmias, hypotension and even cardiac arrest.
Due to myocardial depression effects from its propylene glycol diluent, phenytoin is typically infused no faster than at a rate of 25mg/minute, but rate may be increased to 50 mg/minute during status epilepticus.
Contraindication : Second or Third degree Heart Block.
Valproic Acid
Valproic acid 20 – 40 mg/kg over 2-12 minutes.
Levitracetam
60mg/kg IV, Max:4500 mg/dose
Refractory Status Epilepticus
It is defined as persistent seizure activity despite the IV administration of adequate amounts of two antiepileptic agents.
About 20 -30 % of patients may develop refractory status epilepticus
Patients with refractory status epilepticus requires assisted ventilation.
Third line drugs like midazolam, propofol or phenobarbitone are recommended for continuous infusion depending on the patient characteristics.
Phenytoin/Fosphenytoin, valporate sodium or levitriacetam may also be considered if they have not previously been administrated.
Electrographic seizure control is maintained for 24 -48 hours, followed gradual withdrawal of continuous infusion.
Third Line Agents
Phenobarbitone/Midazolam /Propofol
They are considered as the third line agents .
Studies have shown that patients who don't respond to lorazepam and phenytoin may not respond to barbiturates.
Respiratory depression and hypotension are common when using barbiturates.
Midazolam is preferred over propofol & phenobarbitone in refractory seizures due to risk of Propofol related infusion syndrome and hypotension with propofol & phenobarbitone is assosciated with respiratory depression, hypotension and cardiac depression. Midazolam has an advantage of rapid clearance and short half life.
Refractory Status Epilepticus
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Ketamine
It is a glutamine autogone receptor antagonist.
Ketamine is used as the drug of last resort.
IV Ketamine bolus 1.5 mg/kg then 0.01 – 0.05 mg/kg/hr.
Drug | Initial Dose | Rate of administration & Alternative Dose | Serious Adverse Effects |
Diazepam | 0.15 mg/kg upto 10 mg/dose; may repeat in 5 min. | Pediatric 2-5 years : 0.5mg/kg PR 6-11 years: 0.3 mg/kg PR >12 years : 0.2 mg/kg PR |
Hypotension Respiratory Depression |
Lorazepam | 0.1 mg/kg IV upto 4 mg/dose, may repeat in 5 -10 min |
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Hypotension Respiratory Depression |
Midazolam | 0.2 mg/kg IM | Pediatric : >40 kg :10 mg IM 13 -40 kg : 5mg IM
0.2 mg/kg (intranasal) 0.5 mg/kg (buccal) |
Hypotension Respiratory Depression |
Phenytoin | 20 mg/kg ; may give additional 5 -10 mg/kg | Upto 50 mg/min IV | Arrythmias Hypotension Purple glove syndrome |
Fosphenytoin |
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Valproate sodium | 20 -40 mg/kg IV, may give an additional 20 mg /kg | 3-6 mg/kg/min. May give an additional dose 10 minutes after loading infusion.
Peds : 1.5 – 3 mg/kg/min | Hyperammonemia Pancreatitis Thrombocytopenia Hepatoxicity
Use with caution in patientwith TBI. |
Levitriacetam | 1 – 3 gm IV Peds : 20 -60 mg/kg IV |
2-5 mg/kg/min IV |
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RSE Dosing Recommendation | |||
Drug | Initial Dose | Continuous infusion dosing | Adverse Effects |
Midazolam | 0.2 mg/kg administer at an infusion rate of 2mg/min. | 0.05 – 2 mg/kg/hour Break through SE : 0.1 -0.2 mg/kg bolus, increase CI rate by 0.05 – 0.1 mg/kg/hour every 3 -4 h |
Hypotension Respiratory Depression |
Phenobarbitone | 5 – 15 mg/kg . May give additional 5 -10 mg/kg administer at an infusion rate <50 mg/min | 0.5 – 5 mg/kg/hour Breakthrough SE : 5 mg/kg bolus, increase CI rate by 0.5 -1 mg/kg/hour every 12 h |
Hypotension Respiratory Depression Paralytic ileus |
Propofol | Start 20 mcg/kg/min with 1-2 mg/kg loading dose | 30 -200 mcg/kg/min CI |
Hypotension Respiratory Depression Cardiac depression PRIS |
Role of hypothermia in status epilepticus
It reduces the cerebral metabolic rate, oxygen utilization, ATP consumption, glutaminergic drive, mitochondrial dysfunction, calcium overload, free radical production and oxidative stress, permeability of the blood–brain barrier and pro-inflammatory reactions.
There studies showing sucessful control of SE with Therapeutic hypothermia using thiopental in children's & in adults using midazolam, ketamine.
But in these studies seizures where controlled but they died due to pulmonary embolism , venous thrombosis in person used midazolam. Complications like paralytic ileus was developed on person used thiopental.
It has been found that the seizure control by hypothermia is transient and may return after normothermia.
Currently there is no clinical evidence , Hence mild Therapeutic hypothermia (32- 36C) may be achieved using midazolam or propofol.
Patient should be monitored for coagulation profile, Vein thrombosis, cardiac indices.
ROLE OF SURGERY
It is considered when seizures controlling therapy fails for >2 weeks.
In selected situations, mainly where there is a clearly definable radiological lesion and/or electrophysiological evidence of a focal onset, emergency surgical resection has been used as a ‘last-resort’ treatment of super-refractory status epilepticus.
the operations carried out include focal cortical resection, lobar and multi-lobar resection, anatomic and functional hemispherectomy, corpus callosotomy and multiple subpial transaction.
ETIOLOGY |
Acute Processes
Chronic Processes
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Updated on 13/3/2016
Reference
Evidence based guideline: Treatment of Convulsive status epilipticus in children and adults: Report of the guideline committee of American Epilepsy society. 2016.
Guidelines for Evaluation and Management of Status Epilepticus. Review Article. Neurocritical Care Society. 2012.
The Washington Manual of Critical Care. Second Edition.
Tintinalli. 7Th Edition
Recent Trends in the Management of Status Epilepticus. Review Article. Indian Journal of Critical Care Medicine. 2005. By G. Rajahekher.
Note :
ABG: Lactic acidosis is commonly present for as long as 1 hr after seizure . If it persists for more than one hour think of other cause.
A urinary catheter may be placed to monitor urine output & nasogastric tube to minimize aspiration.
If bacterial meningitis is suspected empiric antibiotic therapy should be started.
Radiographic imaging can be delayed until seizures are controlled.
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emmedonline
Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor