Download status epilepticus

STATUS EPILEPTICUS
(INVESTIGATION & MANAGEMENT)
Presented By: Dr. Dennis Prabhu Dayal
Investigations in Status Epilepticus
 Initial studies
 Blood glucose, electrolytes (sodium, potassium, calcium,
magnesium),urea
 Arterial blood gases
 Anticonvulsant drug levels
 Full blood count
 Urinalysis
 Further investigations after stabilization
 Liver function tests,lactate,creatine kinase
 Toxicology Screen
 Lumbar puncture
 Electroencephalogram
 Brain imaging with computed tomography or magnetic resonance
imaging
Protocol for Management of SE
 Assess A,B,C,GCS
 Give O2 and consider need for intubation/ventilation
 Monitor blood pressure, ECG, Pulse Oximetry
 Obtain I.V. access and draw blood for investigations
 If patient is hypoglycemic or if blood glucose
estimation is not available give glucose: adults: give
thiamine100mg I.V. and 50ml of 50% glucose I.V.
Seizure control:
A. Give benzodiazepine, for example:
 Diazepam: 0.2 mg/kg , I.V. at 5 mg/min up to total
dose of 20 mg.
 Lorazepam: 0.1 mg/kg, I.V. at 2 mg/min up to total
dose of 10 mg.
 Clonazepam: 0.01–0.02 mg/kg, I.V. at 0.5 mg/min
up to total dose of 4mg.
If diazepam stops the seizures, phenytoin
should be given next to prevent recurrence. Repeat
dose every 2–5 min if required.
B. If seizures persist, give Phenytoin:
 Phenytoin: 15–20mg/kg (adults ≤50mg/min) (children
≤1mg/kg/min) or
 Fosphenytoin: 15–20 pheny- toin equivalents (PE) mg/kg,
I.V. (adults ≤150mg/ min) (children ≤3mg/kg per min).
 Additional doses of 5 mg/kg I.V. to a maximum dose of
30mg/kg can be given for persistent seizures.
 Monitor blood pressure and the ECG during infusion.
 If hypotension or arrhythmias develop, stop or slow the
rate of the infusion.
C. If seizures persist (refractory SE), intubate and ventilate
patient. Give either:
 Thiopental: Slow bolus 3–5 mg/kg, I.V. followed by infusion 1–
5mg/kg per hour
 Propofol : slow bolus 1–2mg/kg , I.V. followed by infusion 2–
5mg/kg per hour
 Midazolam: slow bolus 0.1 – 0.2 mg/kg followed by infusion
0.1 – 1.0mg/kg/h
 Titrate doses based on clinical and electrographic evidence
of seizures, targeting electrographic suppression of seizures
or EEG background suppression (isoelectric). Monitor BP
and maintain normotension by reducing infusion rate and/or
giving fluids/ pressor agents.
D. Insert nasogastric tube and administer usual anti-convulsant
medications if patient is receiving treatment for pre-existing
epilepsy.
E. Beware of ongoing unrecognized seizures. Use EEG monitoring
until seizures are controlled and then for 1–2 hours after
seizures stop. Continue to monitor the EEG continuously, or for
periods of more than 30 minutes every 2 hours, during the
maintenance phase. Avoid muscle relaxants (use continuous
EEG if giving repeated doses of muscle relaxants).
F. Discontinue Midazolam or Thiopental, or start reducing
Propofol, approximately 12 hours after resolution of seizures.
Use continuous EEG monitoring and observe for further
clinical and/or electrographic seizure activity. If seizures recur,
reinstate the infusion and repeat this step at 12–24-hour
intervals or longer if the patient’s seizures remain refractory.
OTHER AGENTS OF POTENTIAL USE IN
REFRACTORY SE
 Ketamine acts as an antagonist at the NMDA receptor and may
have a role in the treatment of prolonged refractory SE.
 Intravenous lacosamide is a new anticonvulsant drug available
in intravenous and oral formulations that may be an option for
treatment of established SE after failure of standard therapy, or
when standard agents are considered unsuitable.
 Pregabalin appears to be an interesting option as add-on
treatment in refractory NCSE and may lessen the requirement
for ICU treatment.
 Magnesium is the drug of choice in eclamptic seizures and also
is effective in seizures due to hypomagnesaemia, but there is
little evidence to support its use in other forms of SE
SURGERY
Surgery has occasionally been used in refractory SE
with procedures based on standard epilepsy surgery
techniques. Some success has been reported with
focal resections, subpial transection, corpus
callosotomy, hemispherectomy and vagus nerve
stimulation.
INTENSIVE CARE MONITORING
Monitoring using ECG, intra-arterial and central
venous catheters, capnography and pulse oximetry
should be considered in patients with, or at risk of,
cardio respiratory compromise.
Indications for EEG monitoring:
 Refractory SE, to aid the titration of
anticonvulsant anesthetic drugs (minimizing dose
and toxicity) and ensure suppression of seizure
activity.
 Patients receiving neuromuscular blockade.
 Patients who continue to have a poor conscious
state after apparent cessation of seizures.
 Suspected non-convulsive status epilepticus in a
patient with an altered conscious state.
 Suspected Pseudoseizures
OUTCOME
The prognosis of patients with SE is related to age,
aetiology, degree of impairment of consciousness at
presentation, and duration of SE.
Refractory SE is associated with a worse prognosis and
very prolonged ‘super-refractory’ SE an even higher
mortality.
However, where no underlying irreversible brain
damage is present, good recovery is possible even after
weeks of SE.
Children have a much lower mortality of 3% whereas
those aged over 65 years have a mortality rate of 30%.
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