Status Epilepticus

Diseases,

Diagnosis:

Clinical supported by EEG

Clinical features:

This is an emergency & should be treated as soon as recognised, before EEG or tests
A seizure or multiple seizures without regaining consciousness in between lasting >10 min

Findings on Investigations:

EEG: there is a sequence of EEG findings.
1 discrete seizures
2 merging seizures with waxing and waning amplitude and frequency of EEG rhythms
3 continuous ictal activity
4 continuous ictal activity punctuated by low voltage ‘flat periods’
5 periodic epileptiform discharges PED on a ‘flat’ background

Emergency Treatment:

ABC:

  • Secure airway as necessary
  • Oxygen

Anticonvulsants: if > 10 minutes

  • Lorazepam 0.1mg/kg IV X1 dose favoured over diazepam to interrupt seizures. [VA Cooperative study]
  • Followed by:
    • Fosphenytoin Or Phenytoin PHT 18-20mg/kg IV, aim for level= 20
    • If contraindications or partial status epilepticus, consider: sodium Valproate VPA 25-40mg/Kg IV.

If seizures persist:

  • Propofol 2 mg/kg bolus, followed by infusion
  • Midazolam 0.2 mg/kg bolus IV, 0.1-0.4 mg/kg/hr infusion.(0.75 -11 mcg/kg/min)
  • Some physicians consider Phenobarbital PB 20mg/kg IV X 1 dose, aim for level= 40-60.

For refractory status epilepticus in spite of above measures, consider risk vs. benefit of:

  • Pentobarbital 20 mg/kg bolus, 1-3 mg/kg/hr infusion
  • Thiopentone/thiopental 2-3 mg/kg mg bolus, 3-5 mg/kg/hr infusion

Monitor EEG continuously: aim for burst suppression
Monitor vitals & O2 saturation, alertness
Set up intravenous access
Hyperthermia:

  • Cooling blanket

Treat hypoglycemia +/-thiamine

Further investigations to consider:

Venous blood:
Blood glucose, U&E, Ca++ +PO3–, FBC, ESR, LFTs, antiepileptics levels
toxicology
ABG
ECG
Calculate serum osmolality
CXR: aspiration
Urine toxicology
Consider induction of motor paralysis
Lactic acidosis should not be treated, exclude infection
If >5 minutes intubate & ventilate
EEG monitoring if refractory status i.e. 30-90 minutes
ECG
Calculate serum osmolality
CT head
EEG monitoring
LP
MRI & repeated MRI
Consider:

  • Blood Mitochondrial DNA analysis: Common deletion, POLG mutations
  • Muscle biopsy: mitochondrial disease
  • Brain biopsy
  • CT thorax, abdomen, pelvis: paraneoplastic syndrome
  • Paraneoplastic antibodies

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