Status Epilepticus

Status Epilepticus

Status epilepticus (SE) is a common, life-threatening neurologic disorder that is essentially an acute, prolonged epileptic crisis (see the image below). SE can represent an exacerbation of a preexisting seizure disorder, the initial manifestation of a seizure disorder, or an insult other than a seizure disorder. In patients with known epilepsy, the most common cause is a change in medication. Most seizures terminate spontaneously.  (J.L. Roth, S.A. Berman, , 2014)

Causes

• Cerebrovascular disorders

• Brain trauma

• Infections

• Low anti-epileptic drug levels in patients with epilepsy.

Signs and symptoms

• Focal or unilateral paresthesias or numbness.

• Focal visual changes - usually characterized by flashing lights.

• Focal visual obscuration or focal colorful hallucinations.

• Olfactory or gustatory hallucinations.

• Atypical rising abdominal sensations.

• Muscle spasms.

• Loss of bowel or bladder control.

• Clenched teeth.

• Irregular breathing.

Investigations

• EEG

• Pulse oximetry; blood gases.

• Blood tests for glucose, renal function, electrolytes, liver function, calcium and magnesium; FBC and clotting; AED levels.

• 5 ml of serum and 50 ml of urine samples should be saved for future analysis, including toxicology, especially if the cause of the status epilepticus is uncertain.

• A CT scan or MRI (Tidy, 2012)

Treatments

1. Premonitory stage(pre-hospital) - Diazepam 10−20 mg given rectally, repeated once 15 minutes later. If status continues to threaten, or midazolam 10 mg given buccally.

If seizures continue, treat as below,

2. Early status Lorazepam -  (i.v.) 0.1 mg/kg (usually a 4 mg bolus, repeated once after 10−20 minutes; rate not critical) Give usual AED medication if already on treatment.

For sustained control or if seizures continue, treat as below,

3. Established status - Phenytoin infusion at a dose of 15-18 mg/kg at a rate of 50 mg/minute or fosphenytoin infusion at a dose of 15−20 mg phenytoin equivalents (PE)/kg at a rate of 50-100 mg PE/minute and/or Phenobarbitone bolus of 10-15 mg/kg at a rate of 100 mg/minute.

4. Refractory status - General anaesthesia, with one of: o propofol (1-2mg/kg bolus, then 2-10mg/kg/hour) titrated to effect. o midazolam (0.1-0.2mg/kg bolus, then 0.05-0.5mg/kg/hour) titrated to effect. o thiopentone (3-5mg/kg bolus, then 3-5mg/kg/hour) titrated to effect; after 2-3 days infusion rate needs reduction as fat stores are saturated.

5. Anaesthetic continued for 12−24 hours after the last clinical or electrographic seizure, then dose tapered (giudelines, 2003)

( http://www.educatehealth.ca/media/296429/1-lightbox-epilepsy-treatment-status%20epilepticus.png)

References

• Guidelines, N. (2003, December). Protocol for treating status epilepticus in adults and. Retrieved April 29, 2015, from www.nice.org.uk: http://www.nice.org.uk/guidance/cg20/documents/appendix-c-protocol-for-status-epilepticus-first-consultation2

• J.L. Roth, S.A. Berman, . (2014, April 28). Status Epilepticus . Retrieved April 29, 2015, from emedicine.medscape.com: http://emedicine.medscape.com/article/1164462-overview

• Tidy, C. (2012, 03 14). Status Epilepticus Management. Retrieved 04 29, 2015, from www.patient.co.uk: http://www.patient.co.uk/doctor/status-epilepticus-management