Status Epilepticus
Posted On February 13, 2020
Definition
- A seizure lasting longer than 5 minutes or > 2 seizures without improvement in between.
- This is a true medical emergency
- Most seizures stop on their own after 2-3 minutes
- If a seizure lasts > 10 minutes, it not likely to stop on its own.
- Early treatment has a better chance of stopping the seizure.
Types of Status epilepticus
- Convulsive
- Non convulsive
Initial treatment
- Assess ABC, check lab: cmp, cbc, Tox screen, anticonvulsant levels
- Lorazepam 0.1 mg/kg or 4 mg iv at max of 2 mg/min
- Glucose + thiamine if indicated
- May need intubation
Anticonvulsant loading
- Levetiracetam: 60 mg/kg, max 4500 mg over 15 minutes
- Valproate (Depacon): 30 mg/kg, at 10 mg/kg
- Fosphenytoin: 20 mg/kg pe, atj 150 mg pe/min
- Dec 2019 ESETT: all of the above has similar efficacy.
Other options
- When iv not accessible: midazolam 10 mg im. if weight over 40 kg
- lacosamide (Vimpat) 200-400 mg iv
- Phenobarbital 20 mg/kg at 30-50 mg/min
- Other additions
- Topiramate per NG up to 1600 mg/day., May cause metabolic acidosis.
Refractory status epilepticus
- Intubation
- Midazolam (Versed): water soluble 0.2 mg/kg bolus, at 2 mg/min, may repeat q 5 minutes, to max of 2 mg/kg
- Continuous infusion: titrate 0.1 to 3 mg/kg/hour
- If ineffective, consider propofol or Pentobarbital
- Propofol
- Bolus: 1-2 mg/kg over 5 minutes, may repeat
- Continuous infusion 10-12 mg/kg/hr
- Watch for rhabdomyolysis, acidosis, cardiac and renal failure.
- maintain for 24 hours
- if no clinical and EEG evidence of seizure, wean by 5 percent per hour over 12-24 hours
- Keep patient on a appropriate anticonvulsant at appropriate level
- EEG monitoring: no conclusive evidence that a burst suppression pattern is necessary
Myoclonic status epilepticus post anoxia
- Prognosis is poor, determined by the hypoxia, rather than seizure
- 89% died, 8% vegetative, 3% survive
- If associated with sepsis, uremia, prognosis even worse.