Status Epilepticus

Definition
 Varying and changing, operationally defined as:
≥5 minutes of continuous seizure activity, or ≥1 seizure without recovery in between
 Seizure ≥30 minutes may cause permanent brain damage

Epidemiology
 5% of the world population will have at least 1 episode of seizure
 Annual incidence is higher in developing country
 Lower mortality rate in children (30% vs 3%)
 Equal prevalence in males and females
 Binomial age distribution (extremes of ages)

Causes
 New cases: Idiopathic (62%), stroke (9%), head trauma (9%), alcohol (6%)
 Old cases: Incompliance

Signs and symptoms

 Early and late stages have different presentation
Acute injuries, hypo/hyperthermia, incontinence
 Signs may not be apparent: Pulmonary edema, cardiac failure, rhabdomyolysis may present

First-aid for seizures (very important)

 Remember the first-aids component of seizures
 Do not leave the patient alone after a seizure until normal breathing and able to answer 4Ws
(Who, What, Where, When)

 After episode, go A&E if it is the first epilepsy episode; or else not necessary (check medical history!)
Assessment
First investigations  Anticonvulsant blood levels
 Toxicology screening
 Comprehensive metabolic profile: Electrolyte imbalances, other reversal causes
 Complete blood count: Check WBC for infection; PLT for haemorrhage
 Electrocardiogram: Arrhythmia or cardiac ischemia may occur
 Blood glucose: Hypo-/Hyperglycaemia
Others to consider  EEG, ABG, CT head, lumbar puncture, MRI head, blood cultures

Management
 Treat underlying causes
Causes Treatment
Bacterial infection Anti-bacterial
 Metronidazole
Viral infection Anti-viral
Abscess Surgery
Increased intracranial pressure Neurosurgical decompression
Eclampsia Magnesium and BP management, early delivery
Isoniazid overdose Pyridoxine
Sodium channel blocker overdose Sodium bicarbonate, intralipid
 Pharmacologic management (thiopental, methohexitol, no ketamine)
Time phase Management
0-5 min - Airway ± mechanical ventilation;
Stabilization Preferred: IV propofol or midazolam – Anti-convulsant properties
Not preferred: IV etomidate or neuromuscular blocking agents
(If required, prefer suxamethonium chloride or rocuronium – Short acting)
Neuromuscular blocking may block motor manifestations
EEG monitoring should be used to monitor disease progress
- Thiamine 100mg + glucose
Hypoglycemia is an uncommon cause of Status Epilepticus
**Thiamine should always be given BEFORE glucose infusion to avoid
Wernicke’s Encephalopathy: Activation of glycolysis consume thiamine**
- Pyridoxine should be given for children until metabolic causes been ruled out
- IV access
- Rectal paracetamol for hyperthermia or vasopressors for hypotension
5-20 min - Benzodiazepines (First-line agent)
Initial Therapy IV Diazepam: High lipophilicity
 Fastest onset (10-20s);
 Shortest duration (<20 mins), IV access required
IV Lorazepam
 Longer duration of action (4-12 hours), fast onset (2 mins)
 IV access required
IM Midazolam (or buccal)
 IV access NOT required
 Short half-life in CNS
- Can be re-dosed after 5 minutes if ineffective
- Side effects: hypoventilation, cardiac rhythm disturbances
20-40 min - Likely to be equally effective and have similar rates of adverse effects
Secondary Therapy - IV Fosphenytoin (20mg/kg IM or IV)
Better tolerability and faster infusion than phenytoin
(i.e., local site irritation, less hypotension from propylene glycol)
Life threatening rash in Asians with HLA-B*1502
IM should not be used due to unpredictable level and slow onset
- IV Valproate acid
May be more efficacious/tolerable than fosphenytoin
Risk of hepatoxicity and coagulopathy
- IV levetiracetam (not preferred on HA formulary)
Least drug interactions and hepatotoxicity, need renal dose adjustments
Least risk on major birth defects or effect on oral contraceptive efficacy
40-60 min - Repeat previous treatments
Refractory phase - Induce coma by pentobarbital, midazolam and propofol
(10-20% of cases) - Midazolam
Tachyphylaxis rapidly develops within 24-48 hours
Dose may need to be increase after 1-2 days
- Propofol (Continuous infusion: Half-life is very short 3-10 minutes)
Less seizure recurrence than midazolam
Contraindicated in patients with hypotension, always check BP!
- Pentobarbital/phenobarbitone
More hypotension but maybe better efficacy
- Send to ICU as soon as possible for EEG monitoring and further management