STATUS EPILEPTICUS

Dr.Gireesh kumar.K.P
Definitions
• Seizures: it is a paroxysmal event due to
abnormal excessive hypersynchronous
discharges from an aggregate of CNS neurons.
• Epilepsy: it is a condition in which a person has
recurrent seizures (two or more unprovoked
seizures) due to a chronic underlying process.
• Convulsions : motor component of a seizure are
called as convulsions
Status epilepticus
• Status epilepticus is defined as > 5 -10 minutes of
continuous seizure activity or a series of seizures
without return to full consciousness between the
seizures
Classification
• 1.Convulsive status –
• Generalized tonic clonic status
• Partial : epilepsia partialis continua
• 2.Non convulsive status –
• Absence status
• Complex partial status
• 3.Neonatal status epilepticus
Causes
• Antiepileptic drug noncompliance or discontinuation
• Alcohol induced seizures or withdrawal seizures
• Acute structural brain injury (eg, brain tumor or cerebral metastasis,
stroke, head trauma, subarachnoid hemorrhage, cerebral anoxia or
hypoxia) or infection (encephalitis, meningitis, abscess).
• Metabolic abnormalities (eg, hypoglycemia, hepatic encephalopathy,
uremia, pyridoxine deficiency, hyponatremia, hyperglycemia,
hypocalcemia, hypomagnesemia)
• Use of, or overdose with drugs that lower the seizure threshold (eg,
theophylline, imipenem, high dose penicillin G, quinolones,
metronidazole, isoniazid, tricyclic antidepressants (especially
bupropion), lithium, clozapine, flumazenil, cyclosporine, lidocaine,
bupivacaine)
Investigation
• Oxygen saturation , ABG
• Blood sugar,
• Serum calcium, sodium, magnesium,
phosphorous
• LFT, RFT, Infection screen, CSF study
• Drug screen , anti epileptic drug levels
• CT/MRI brain, EEG
Management - ABC
• Clear mouth,secreation, artificial dentures
• Administer oxygen if needed
• Monitor ECG and blood pressure
• Intravenous (IV) line should be secured
• IV Thiamine (100 mg) and dextrose (50 mL of 50
percent dextrose solution) should be considered.
• If no seizures - Left lateral position to prevent
aspiration
Left lateral postion to prevent aspiration
Start with - Lorazepam

I V Lorazepam 0.1 mg to 0.15 mg kg/hr

Lorazepam - alternatives
• IV Diazepam 0.1 to 0.3 mg/kg, effect lasts for <20 min.
• OR
• IV Midazolam 0.2 mg/kg bolus, followed by continuous
infusion at 0.75 to 10 mcg/kg/minute.
• If IV access is not available, intramuscular (IM) midazolam is
a safe and effective alternative
• Midazolam can be given at a dose of 10 mg IM, nasally or
buccally, for patients with a body weight >40 kg and 5 mg for
patients with a body weight of 13 to 40 kg
After 5 minutes - seizure persisting

Repeat Lorazepam 0.1 to 0.15 mg /kg/hr

If seizure does not subsiding
• IV Fosphenytoin 20 mg /kg infusion rate at 150 mg /
min –
• Advantages are can be given more rapidly, lesser
adverse effects.
• The increased water solubility of fosphenytoin
makes IM injections possible if IV access cannot be
obtained.
Fosphenytoin - alternative
• IV Phenytoin 20 mg/kg infusion (in Normal saline)
rate at 50 mg/ min
• The risks of hypotension and cardiac arrhythmias,
local pain and injury increase with higher infusion
rates of phenytoin.
• Phenytoin and fosphenytoin, both may intensify
seizures caused by cocaine, other local
anesthetics, theophylline, or lindane(gammaxene: an
agricultural insecticide and as a pharmaceutical
treatment for lice and scabies)
Seizure continuing
• Repeat - IV Fosphenytoin 20 mg /kg infusion rate at 150 mg / min

• Or

• IV Sodium Valproate 25 mg/kg and levetiracetam 40 to

60 mg/kg (maximum 4500 mg) are reasonable alternatives
to fosphenytoin
Seizure continuing
• IV phenobarbital 20 mg/kg infusion rate at 60
mg/min
• OR
• IV lacosamide (200 to 400 mg IV bolus) maintenance
200 mg
Seizure continuing
• IV phenobarbital 10 mg/kg at 60 mg/min.
• After the loading dose ,start infusion of pentobarbital
1 to 4 mg/kg/hour to maintain the patient in a
seizure-free state.
Seizure continuing
• Admit to ICU Anesthesia with midazolam or propofol
• Midazolam (0.2 mg/kg load followed by 0.75-10
mcg/kg/min infusion)
• Propofol (2 mg/kg load followed by 30-250 mcg/kg/min
infusion).
• Others — Ketamine, IV: 1 to 2 mg/kg over 30 to 60
seconds., is an N-methyl-D-aspartase (NMDA) antagonist
that has promise as a treatment for refractory status
epilepticus
Seizure in eclampsia
• Inj. Magnesium Sulphate IV
• 6 gm bolus over 15 minutes IV
• 1 to 3 gm/hour continuous infusion
• OR
• 10 gm (5 gm on each buttock) IM
• Maternal toxicity is rare when MgSO4 is carefully administered and
monitored. The first warning of impending toxicity in the mother is loss
of the Knee jerk at levels of 3.5 and 5 mmol/L. Respiratory paralysis
occurs at 5 to 6.5 mmol/L. Cardiac conduction is altered if >7.5 mmol/L,
and cardiac arrest can be expected when concentrations of magnesium
>12.5 mmol/L.
• Phenytoin is an alternative, although less effective, therapy.