Status Epilepticus Made Simple

TERMINOLOGIES

1. Seizure: Abnormal or excessive neuronal discharge causing a transient disturbance of cerebral function.

2. Epilepsy: A condition characterized by recurrent (≥2) unprovoked seizures.

3. Status Epilepticus (SE):

a. Conventional definition: 2 fits occur without recovery of consciousness in between or a single fit lasts longer than 30 minutes with or without loss of consciousness. The rationale behind the time limit of 30 minutes is that – irreversible neuronal injury may occur after 30 minutes of seizure activity.

b. New ILAE task force definition:

  • A condition resulting either from:
    • Failure of the mechanisms responsible for seizure termination or
    • From the initiation of mechanisms
  • Leading to abnormally prolonged seizures (after time point t1) i.e. demarcation of time when treatment should be initiated
    • Tonic-clonic SE: 5 min
    • Focal SE with impaired consciousness: 10 min
    • Absence SE: 10-15 min
  • And can have long-term consequences (after time point t2) – including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures.
    • Tonic-clonic SE: 30 min
    • Focal SE with impaired consciousness: 60 min
    • Absence SE: Unknown

4. Refractory Status Epilepticus: SE not responding to atleast 2 doses of Benzodiazepines, followed by phenytoin/valproate and phenobarbitone or midazolam infusion beyond 60 minutes after the treatment has started.

CLASSIFICATION OF STATUS EPILEPTICUS

A) With Prominent Motor Symptoms:

  1. Convulsive SE (Tonic-clonic)
  2. Myoclonic SE (Prominent epileptic myoclonic jerks)
  3. Focal motor: Repeated focal motor seizures (Jacksonian), Epilepsia Partialis Continua (EPC), Adversive status, Oculoclonic, Ictal paresis
  4. Tonic SE
  5. Hyperkinetic SE

B)Without Prominent Motor Symptoms (Non-convulsive i.e. NCSE):

  1. NCSE with coma
  2. NCSE without coma
    • Generalized: Typical absence, Atypical absence, Myoclonic absence
    • Focal: Without impairment of consciousness, Aphasic status, With impaired consciousness
    • Autonomic SE

ETIOLOGY OR CAUSES OF STATUS EPILEPTICUS

1. Known (Symptomatic):

  • Acute: Sudden antiepileptic withdrawl, Stroke, Intoxication, Metabolic disorders (hypoglycemia, hyponatremia), Alcohol or Benzodiazepine withdrawl, Malaria, Encephalitis, etc.
  • Remote: Post-traumatic, Post-encephalitic, Post-stroke, etc.
  • Progressive: Brain tumor, Lafora’s disease and other Progressive Myoclonic Epilepsy (PME), Dementia
  • SE in defined Electroclinical syndromes

2. Unknown (Cryptogenic)

DIFFERENTIATING STATUS EPILEPTICUS FROM PSEUDOSTATUS

status epilepticus vs pseudostatus

MANAGEMENT OF STATUS EPILEPTICUS

status epilepticus management

Mnemonic: AAP

0-5 minutes (A):

  • ABCs
  • AMPLE hisotry (Allergies, Medications, Past medical history, Last meal, Events preceding)
  • Adjuncts
    • Left lateral position to prevent aspiration
    • Administer oxygen
    • IV access
    • Blood samples for glucose, RFT, Electrolytes, LFT, ABG analysis, Anticonvulsant levels
    • If hypoglycemic: Thiamine 100 mg IV followed by Dextrose 50 gm IV (In thiamine deficients, PDH reaction for converting Pyruvate to Acetyl-CoA requiring TPP cofactor doesn’t work leading to shunting of pyruvate to lactate formation; without thiamine replacement – all glucose supplemented goes into pathway of lactate formation)

5-10 minutes (A):

Equivalent dose of Benzodiazepines: Chlordiazepoxide 25 mg = Temazepam 10 mg = Diazepam 5 mg = Lorazepam 1 mg = Alprazolam 0.5 mg = Clonazepam and Triazolam 0.25 mg

  • Ativan (Lorazepam): 0.1 mg/kg (max 2 mg in children); 2-4 mg in adults at the rate < 2 mg/min
    • Can cause respiratory depression and decreased BP
    • May be repeated if needed OR
    • Midazolam 10 mg I.M. (repeate if needed)

10-20 minutes (P):

  • Phenytoin 20 mg/kg IV at < 50 mg/min (adults) and < 25 mg/min (children) – total dose < 1000 mg (risk of hypothension and bradyarrhythmias) OR
  • Phosphenytoin 20 mg PE (1.5 mg Phosphenytoin = 1 mg Phenytoin)/kg at <100-150 mg/minute (less risk of hypotension compared to phenytoin)

A: ABCs

A: Ativan repeat

20-30 minutes (P):

  •  Phenobarbital 20 mg/kg at < 50 mg/min

A: ABCs, Anticipate Intubation; Volume bolus may be needed

>30 minutes (A): Ativan repeated

40-60 minutes (P):

  • Phenobarbital repeated 10 mg/kg

A: ABCs, Intubate

A: Arterial line for BP monitoring and Central line for dopamine infusion considered

P: Patient to ICU for Propofol, Midazolam or Pentobarbital

  • Midazolam 0.2 mg/kg iv infusion at 0.2-0.6 mg/kg/hr
  • Propofol 2 mg/kg loading followed by iv infusion 2-5 mg/kg/hr
  • Pentobarbital 5 mg/kg loading followed by iv infusion 1-5 mg/kg/hr

Add Comment