Download Status epilepticus

Status epilepticus
Dr Karen Goodfellow
Definition

Seizure lasting >30 min
–

or
Repeated seizures without intervening
consciousness
Differential diagnosis
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Epilepsy
–
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
Drug or alcohol withdrawal
Overdose
–
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



tricyclics, phenothiazines, amphetamines
Hypoxia
CVA, SAH
Infection
Metabolic
–

stopping treatment; illness; alcohol; poor compliance
hypoglycaemia, deranged Ca, Mg, Na, thyroxine, urea, bilirubin
Pseudo-seizures
Consider pregnancy
Investigations


After treatment
Bloods
–

Glucose, ABG, U&E, Ca, FBC, LFT, Mg
Consider
–
Anticonvulsant levels, toxicology screen, LP,
cultures, EEG, CT, CO level
Management

Maintain airway & recovery position

O2 and suction

IV access
–
large bore

Monitoring

Consider
–
–
Thiamine 250mg IV
IV glucose
Early drug treatments
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Premonitory stage (pre-hospital)
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Lorazepam
–
–
–
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Diazepam 10-20mg PR
0.1mg/kg (4mg slow bolus IV (3-4 mins large bore))
Beware respiratory arrest
Rpt after 10-20 mins
Or
Diazepam (not NICE)
–
–
10mg slow bolus IV
Less long lasting
Established status
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Phenytoin infusion
–
–
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15-18mg/kg IVI
Rate of ≤50mg/min
SE
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–
CI
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Bradycardia and heart block
Maintenance dose (not NICE)
–

hypotension; dysrhythmias
100mg/6-8 hours
Phenobarbitone
–
–
Bolus
10-15mg/kg, rate of 100mg/minute
Refractory status

General anaesthetic
–
–
–
May be required for paralysis and ventilation if lorazepam
+/- phenytoin fails
One of:
Propofol

–
Midazolam

–
0.1-0.2mg/kg bolus, then 0.05-0.5mg/kg/hr
Thiopentone


1-2mg/kg bolus, then 2-10mg/kg/hr
3-5mg/kg bolus, then 3-5mg/kg/hr
Continued for 12-24 hours after last clinical or EEG
seizure
Refractory status

Diazepam infusion
–
–

100mg in 500ml 5% dextrose
40 ml/hour
Dexamethasone
–
–
10mg IV
Considering cerebral oedema
Long term therapy



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In parallel with emergency treatment
Previous therapy, type of epilepsy, clinical
setting
Continuation previous therapy
Reverse reductions
Continuation PO/IV maintenance of
phenytoin/phenobarbitone
Non-convulsive status epilepticus


Maintenance or reinstatement of usual
therapy
IV benzodiazepines under EEG control,
particularly if diagnosis not established