Status Epilepticus

Empirical Treatment

Oxygen

Thiamine 100mg-250mg IV

Glucose 50ml of 50%

Rx: (see below for evidence)

[Lorazepam

IV 4mg as slow bolus (2min)

Diazepam

IV 10mg as slow bolus (2min)

If needed repeat 5mg per minute to 20mg

PR ~10-20mg (0.5mg/kg)

Midazolam

IV

Start with 1-2mg increments

Up to 0.0.02-0.2mg/kg

IM ~10mg (0.1-0.2mg/kg)

Intranasal 0.2mg/kg

Buccal 10mg

Clonazepam

IV 1mg slow bolus (repeat if necessary)

Halve dose for child

2^nd Line

Phenytoin

Infusion 15-20mg/kg at <50mg/min

Followed by a further 5mg/kg

(Beware dec BP and do not use if bradycardic or heart block)

Start early as does not work until 50% of dose delivered

Status Epilepticus

• Generally classified as longer than 30min seizure
• However should treat if longer than 5min or greater than 2 seizures in a row without recovery of conciousness in between

• 25-50% is non-convulsive
• 50% occurs in patients without a diagnosis of epilepsy

Physiological effects

• Damage by excitatory amino acid neurotransmitters – glutamate and aspartate
• Lead to excess calcium and osmotolysis
• Hypoxia
• Hypoglycaemia
• Lactic acidosis
• Hyperthermia

Causes

• 50% epilepsy
• Treatment withdrawal
• Co-existent illness

Other (i.e. 50% occurs in patients without diagnosis of epilepsy)

• Children
• Infection with fever
• Adults
• Stroke
• Hypoxia
• Metabolic derangements
• Alcohol intoxication or withdrawal

Investigations:

Glucose

U+E

Calcium

FBC

Anticonvulsant level

Toxicology screen

Blood culture

LP

Carbon Monoxide level

Prolactin level (may help distinguish pseudoseizure)

Treatment (see above for doses)

Left Lateral position

Oxygen

Soft nasal airway (do not prize apart teeth)

Drugs

Diazepam

• Effective in 60-80%
• Elimination half-life 30hours however redistribution half life of 30min
• 50% chance of seizures recurring within 2 hours
• Rectal and IV similar efficacy
• SE: Sedation, respiratory depression, Hypotension

Lorazepam

• Effectiveness 60-90%
• Similar to diazepam but better redistribution profile

Midazolam

• Buccal route 75% effective
• Rapid administration an advantage

Phenytoin

• To be used with benzodiazepine in resistant cases
• Not effective on its own
• SE: Sedation, Respiratory depression, Hypotension, Rash, Purple glove syndrome (ischaemia of hand)

Prognosis

• Convulsive status
• mortality 10-20%
1. <1hour 2.7
2. >1hour 32%
• Risk of cognitive decline and development of epilepsy
• Refractory status
• Mortality 48%
• 29% of patients return to premorbid level of function

References

• BMJ 2005 331: 673