Download Generalized Convulsive Status Epilepticus (Judy Liu MD/PhD)

Generalized Convulsive Status Epilepticus (Judy Liu MD/PhD)
Convulsive status epilepticus is defined clinically as a single seizure lasting greater than 5
minutes or multiple seizures without recovery of consciousness in between. Generalized
convulsive status is a life threatening emergency, and prompt intervention is key to
management. Treatment of status consists of stabilizing the patient with respect to
ABC’s – (airway, breathing, and circulation), assessing for acute medical problems such
as hypoglycemia, and then treating the seizures promptly with anti-epileptic drugs
(AED’s).
The first 3 minutes:
-ABC- airway, breathing, circulation
-Blood pressure and pulse prior to administration of AED
-cardiac telemetry since seizures can cause cardiac arrhythmias
-Access--peripheral IV
-rectal route is sometimes used for administration of AED out of hospital.
-Fingerstick glucose –and give thiamine 100mg first, then 50ml 50% glucose
-LabsCBC
PT, PTT and INR
Electrolytes including Chem 7, Ca, Mg, PO4
Liver function tests
Toxicology screen including narcotics, cocaine,
AED levels
Medications and Considerations- start giving meds as soon as IV access is obtained,
you can go in the order listed below. However, even if seizures respond to
benzodiazepines, a longer acting agent will need to be given to control seizures once the
benzodiazepine wears off. High dose suppressive therapy with continuous EEG
monitoring should be considered when adequate trials of two medications from different
classes have failed to control seizures. In that case, choice of agent depends on patient
characteristics including age and co-morbid factors.
-Lorazepam (Ativan) 1-2mg IVP q5min typically for a total of 8mg
-Onset of action is 6-10 minutes
-Anti-epileptic activity 12-24 hours is longer than diazepam.
-Diazepam (Valium) 5-10mg IVP q5-10 min up to 40mg
- very short duration of anti-seizure activity, 20-40 min, and a very long
half-life of sedation and respiratory depression, 48-72 hours, so it should
not be used to control status epilepticus, although we still see it used
occasionally.
-Onset of action is within 1-3 minutes.
-Phenytoin (Dilantin) or Fosphenytoin (Cerebyx)-needs to be given even if
seizures have stopped with benzodiazepine.
-Phenytoin can be loaded at no faster than 50mg/min, Fosphenytoin can be
given at up to a rate of 150mg/min.
-If the patient continues to seize, can give repeat boluses of 5mg/kg, not
exceeding a total of 30mg/kg.
-A post- load level can be checked which should be > than 20 g/ml
-Infusion related hypotension is more common with IV phenytoin than
fosphenytoin.
-- Acute loading with phenytoin often causes loss of eye movements for
up to 12-24 hours
-Valproic Acid (Depacon) - can be loaded at 20-30 mg/kg,
-not as widely used as phenytoin or Phenobarbital
-non-sedating and no hypotension
-Phenobarbital –
-load 20mg/kg, rebolus as needed 5-10 mg/kg
-no limit to the amount which can be used, but it has an extremely long
half-life, so that another agent should be considered before getting to
extremely high levels.
-Continuous EEG monitoring is recommended at this point.
-Decreased respiratory drive and hypotension
-May require intubation.
-Pentobarbital –patient is intubated on continuous EEG monitoring.
-load at 5-15mg/kg over 1hour
-maintenance infusion at 1-5 mg/kg/h/ per hour titrating up by 1mg/ kg/
hour until no seizure activity or burst suppression.
-Causes hypotension and often requires use of pressors to maintain blood
pressure.
-Propofol-patient is intubated on continuous EEG monitoring.
-load 1-2mg/kg, then infuse 2-10mg/kg/h/ titrate to control seizure activity
or burst suppression on continuous EEG.
-Complications include hyptension and metabolic acidosis.
-Midazolam (Versed) -patient is intubated on continuous EEG monitoring.
-load 0.15-0.2mg/kg, then 0.05-0.3mg/kg/h/ titrate to control seizure
activity or burst suppression on continuous EEG.
-less hypotension and reduction of respiratory drive than barbiturates.
Once the seizures are under control, the main goal is to identify and treat the cause
of status epilepticus.
Imaging- CT to evaluate for bleeding, and/or MRI for stroke or mass lesion
Lumbar puncture- to evaluate for infectious cause or subarachnoid hemorrhage
EEG- to make sure the patient has stopped seizing. It is especially important to
evaluate for electromechanical dissociation in patients who remain unresponsive.
Etiology of Status
with known epilepsy
No history of seizure disorder
-sudden discontinuation of AED -stroke
-change in treatment regimen
-meningo-encephalitis
-barbiturate or benzodiazepine
-drug overdose- tricyclics, phenothiazines,
withdrawal
theophilline, isoniazid, cocaine,
-alcohol abuse
amphetamines, phencylidine
-pseudoseizure- ie pseudostatus
-acute head injury
-cerebral neoplasm
-metabolic- hypoglycemia, hypocalcemia,
hyponatremia, renal failure, and
hepatic failure
-vasculitides/ demyelinating dz