Status epilepticus resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]; Rim Halaby, M.D. [3]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. The causes by themselves are usually not life threatening.

Management

Shown below is an algorithm summarizing the approach to status epilepticus.

Characterize the symptoms: ❑ Aura: altered vision and/or hearing and/or ❑ Tonic phase with muscle spasms and/or ❑ Rapid jerky movement and/or ❑ Uprolling of eyes and/or ❑ Tounge bite and/or ❑ Incontinence

General measures (Emergency): Begin initial care: ❑ Turn patient to side ❑ Secure airway ❑ Assess respiratory and cardiac functions ❑ Administer high concentration O2 ❑ Establish IV access ❑ Institute regular monitoring for pulse, blood pressure, temperature ❑ ECG monitoring ❑ Check glucose level, and correct hypoglycemia if present (Urgent) Order labs: ❑ Full blood count ❑ Plasma electrolytes ❑ Blood gases ❑ Glucose ❑ Renal and liver function ❑ Serum calcium and magnesium ❑ Blood clotting br> ❑ Drug levels (if patient is on AED) ❑ Obtain 5 ml of serum and 50 ml of urine sample for toxicology screen Consider vitamin deficiencies: ❑ Administer glucose (50 ml of 50% solution) and/or IV thiamine (250 mg) if suspected alcohol abuse or impaired nutrition ❑ Supplement IV pyridoxine if suspected pyridoxine deficiency Consider the possibility of non-epileptic status Treat acidosis if severe

Administer AED (Emergency): ❑ First line therapy: IV lorazepam (0.1 mg/kg at 2 mg/min, 4 mg bolus) or ❑ Second line therapy: Buccal midazolam (10 mg) or rectal diazepam (10-20 mg) if IV access could not be established or IV lorazepam is not available

Recurrent or ongoing seizure 10 min after onset? (Urgent) ❑ Repeat the previous regimen only ONCE

Recurrent or ongoing seizure 30 mins after onset? (Urgent) ❑ IV phenytoin (15-18 mg/kg at 50 mg/min): Slow IV infusion, IM is not recommended, monitor ECG during the infusion or ❑ IV fosphenytoin (15-20 mg phenytoin equivalents (PE)/kg at 50-100 mg PE/min): monitor ECG during the infusion or ❑ IV phenobarbital (10-15 mg/kg at 100 mg/min)

Ongoing seizure 60 mins after onset? (Urgent) ❑ Intubate and ensure full intensive care support ❑ Anesthetize with midazolam (0.1-0.2 mg/kg bolus, then 0.05-0.5 mg/kg/hour), OR thiopental (3-5 mg/kg bolus, then 3-5 mg/kg/hour, OR propofol (1-2 mg/kg bolus, then 2-10 mg/kg/hour) titrated to effect; reduce the dose after 2-3 days as fat stores are saturated ❑ ICU admission

References

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