Status Epilepticus

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.

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