STATUS EPILEPTICUS

BY
DR MUHAMMAD USMAN
DR AREEBA NAEEM
 STATUS EPILEPTICUS
 The seizure with 5 minutes or more of continuous clinical activity or
electrographic seizure activity or recurrent seizure activity without
recovery in between seizures.
 TYPES OF STATUS EPILEPTICUS

→ Convulsive status epilepticus
 Generalized tonic
 Clonic
 Tonic clonic

→ Non convulsive status epilepticus
 Focal with impaired awareness
 Absence
 TYPES OF STATUS EPILEPTICUS
→ Refractory status epilepticus
Failed to respond to therapy with at least two medication ( benzodiazepine and another
drug).

→ Superrefractory status epilepticus

Failed to resolve, or recurs, within 24 hr or more despite therapy ( continuous infusion
midazolam or pentobarbital).
or epilepsy.
 TYPES OF STATUS EPILEPTICUS
→ New onset refractory status epilepticus
That can be caused by any of the cause of SE in a patient without prior epilepsy.

→ Fever induced refractory epileptic encephalopathy in school

age children
Syndrome of refractory SE that is associated with acute febrile infections, appears to be highly
drug resistant.
 ETIOLOGIES
 NEONATES  CHILD
1. Hypoxic ischemic encephalopathy 1. Infections
2. Infections 2. Anticonvulsant withdrawal
3. Simple febrile seizure
3. Inborn errors of metabolism
4. Metabolic disturbances
4. Stroke or intraventricular
5. Congenital malformation
hemorrhage
6. Presentation of epilepsy
5. Pyridoxine deficiency and
7. Trauma
dependence
 MANAGEMENT
 Status epilepticus is a medical emergency and requires immediate
treatment. Main goals of treatment are:
 Initial stabilization of vital functions
 Terminate seizure activity
 Evaluate and treat underlying cause
 STABILIZATION PHASE (0-5min)
 Stabilize patient ( airway, breathing, circulation, disability-neurology exam)
 Time seizure fromits onset, monitor vital signs
 Asses oxygenation,give oxygen via nasal cannula/mask, consider intubation if
respiratory assistance needed.
 Initiate ECG monitoring
 STABILIZATION PHASE (0-5min)
→ Collect finger stick blood glucose.if glucose is <60mg/dl then
Adults: 100mg thiamine IV then 50ml D50W IV
Children > 2years: 2ml/kg D25W IV Children < 2years: 4ml/kgD12.5W IV
→ Attempt IV access and collect sample for
1. CBC and serum electrolytes
2. glucose
3. calcium
4. magnesium concentration
5. toxic screen
6. levels of anticonvulsants medications
 INITIAL THERAPY PHASE (0-20min)
 Benzodiazepine is the initial therapy of choice :
One of following 3 drugs are used as first line therapy:
1. Midazolam IM (10mg > 40kg, 5mg 13-40kg single dose)
2. Lorazepam IV ( 0.1mg/kg/dose, max 4mg/dose ,may repeat once)
3. Diazepam IV ( 0.15-0.2mg/kg/dose, max 10mg/dose, may repeat once)
 INTIAL THERAPY PHASE (5-20MIN)
 If none of above 3 are available 3 options:
 Phenobarbital IV ( 15mg/kg/dose single dose)
 Diazepam rectal (0.2-0.5mg/kg, max 20mg/dose)
 Midazolam intranasal (0.2mg/kg)
 Midazolam buccal (0.5mg/kg)
IF SEIZURES CONTINUE
 SECOND THERAPY PHASE (20-40min)
 One of the following 3 drugs are used as second line option and give as a single
dose
1.Fosphenytoin IV ( 20mg PE/kg, max 1500mgPE/dose, single dose)
2. Valproic acid IV (40mg/kg, max 3000mg/dose single dose)
3. Levetiracetam IV (60mg/kg, max 4500mg/dose single dose)
If none of above is available ,then (if not given already):
Phenobarbital (15mg/kg, max dose)
If seizure still continue
 THIRD THERAPY PHASE (40-60min)
 There is no clear evidence to guide therapy in this phase:
 Choices includes
 Repeat second line therapy
 Anesthetic doses of either thiopental, midazolam, pentobarbital, propofol
(all with continuous EEG monitoring)
NOTE: when a drug is selected to be used, sufficient time must be allowed for the
drug to act before more of the same medication or another medication is used
 COMPLICATIONS
 Primary complications associated with SE are side effects of therapyand systemic effects caused by the
prolonged seizure.
Complications are:
1. Hypoxia
2. Lactic acidosis
3. Hyperkalemia
4. Hypoglycemia
5. Shock
6. Hyperpyrexia
7. Renal failure
8. Pulmonary failure