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• 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.

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.

• 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.

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.

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. 7^Th 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.