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EVALUATION AND MANAGEMENT OF
STATUS EPILEPTICUS |
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Definition
Status epilepticus is defined as a continuous single
seizure or repetitive individual seizures with no recovery of consciousness
between attacks, lasting at least 30 minutes. In clinical practice,
patients who are noted to seize for longer than 10 minutes are treated as if in
status, since most seizures terminate in 1-2 minutes.
Status is classified as generalized or partial (focal); and convulsive or
nonconvulsive. While the majority of cases are recurrent generalized
tonic/clonic, nonconvulsive status can include absence and complex partial
status epilepticus. Partial, focal clonic activity is referred to as epilepsia
partialis continua (EPC). While the diagnosis is usually made clinically, an EEG
that reveals continuous seizure activity is also diagnostic of status
epilepticus. Generalized tonic clonic status
epilepticus is considered a medical emergency. If untreated, it is
associated with a high morbidity and mortality. |
Management of Generalized Tonic Clonic Status
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Assess Airway, Breathing and Circulation (ABCs) |
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Administer O2
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Monitor cardiac rhythm, O2 saturation and vital signs
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Bedside glucose test |
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Draw blood for anti-epileptic drugs, hematology, and chemistries
studies, and toxicological screens |
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Establish intravenous line |
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Administer thiamine 100 mg
IV followed by 50 mL of 50% glucose
by direct push |
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Administer intravenous lorazepam
(ativan) at 2 mg/min up to a total dose of 0.1 mg/kg |
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Simultaneously administer fosphenytoin
15-20 mg kg (up to 150 mg/min) |
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If status persists, give additional dose of 5-10 mg/kg of
fosphenytoin to a maximal dose of
30 mg/kg |
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If status persists, intubate and place an arterial line |
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Administer phenobarbital 20
mg/kg IV at 50-100 mg/min. If seizures continue, give an additional
5-10 mg/kg of phenobarbital. |
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If status persists, consider pharmacological coma with either
midazolam (loading dose of 0.2
mg/kg by slow intravenous bolus, then 0.75-10.00 μg/kg/min),
propofol (loading dose of 12 mg/kg
IV, followed by 2-10 mg/kg/hr), or
pentobarbital (5-15 mg/kg IV bolus over 1 hour, followed
by 0.5-3.0 mg/kg/hr).
Continuous EEG monitoring is indicated throughout therapy, with the
primary endpoint being suppression of EEG spikes or a
burst-suppression pattern with short intervals between bursts.
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