Neuroscience Clerkship

 

 

EVALUATION AND MANAGEMENT OF STATUS EPILEPTICUS

EEG: Patient going into a generalized seizure

 

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

Assess Airway, Breathing and Circulation (ABCs)
Administer O2
Monitor cardiac rhythm, O2 saturation and vital signs
Bedside glucose test
Draw blood for anti-epileptic drugs, hematology, and chemistries studies, and toxicological screens
Establish intravenous line
Administer thiamine 100 mg IV followed by 50 mL of 50% glucose by direct push
Administer intravenous lorazepam (ativan) at 2 mg/min up to a total dose of 0.1 mg/kg
Simultaneously administer fosphenytoin 15-20 mg kg (up to 150 mg/min)
If status persists, give additional dose of 5-10 mg/kg of fosphenytoin to a maximal dose of 30 mg/kg
If status persists, intubate and place an arterial line
Administer phenobarbital 20 mg/kg IV at 50-100 mg/min. If seizures continue, give an additional 5-10 mg/kg of phenobarbital.
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.