Status Epilepticus

Status Epilepticus

This is a protracted seizure. By definition, status epilepticus is a seizure that has lasted for > 30 minutes without intervening consciousness (but in reality, it is considered if a seizure lasts > 5 minutes). The most common cause is non-compliance with the anti-epileptic drug regimen in patients with known epilepsy. For the first minutes (atonic phase), the patient is usually not breathing. The most important first step is therefore to maintain the airway.

Never spend more than 20 minutes on someone with status epilepticus without assistance from an anaesthetist.

• Differenitals
  • Delirium tremens: History of heavy alcohol use with sudden cessation
  • Neuroleptic malignant syndrome: antipsychotic medication. The patient is febrile, rigid and has fluctuating conscisounses
  • Drug ingestion: rule with urine toxicoology. Needle track marks on the arms.
  • Pseudo-status epilepticus: NEVER assume that a patient is faking a seizure!
• Treatment of status epilepticus
  • 5 minutes
    • ABCs
      • Open and secure the airway (adjuncts as needed)
      • Remove false teeth if they are poorly fitting
      • Give 100% oxygen and suction as needed
      • EKG monitor
    • IV access and draw blood
      • Labs (Blood glucose, CBC, U/E/C, LFTs, Urine toxicology, AEDs level)
    • IV Lorazepam 4mg at 5 minutes or IV Diazepam 10mg STAT or Midazolam
    Lorazepam does not require refridgeration 10-20mg Diazepam can be given PR if IV access cannot be established (rectal solution at 0.5 mg/kg)Midazolam can be given Buccaly if IV access cannot be established
    • Have full resuscitation facilities on hand for all IV benzodiazepine use
    • If blood glucose is unavailable assume hypoglycemia
      • Give Thiamine 250mg IV over 30 minutes then 50mL D50 (always give glucose with thiamine to prevent Wernicke-encephalopathy)
  • No response at 10 minutes
    • Second dose IV Lorazepam if no response (or Diazepam, Midazolam)
    • IV Phenytoin loading if the patient is in hostpital
  • No response at 15 minutes
    • Consult Anaesthesia or Intensivist
      • Prepare for impending mechanical intubation
      • Preparr for general anesthesia
  • No response at 20 minutes
    • IV Phenobarbital
    • Insert foley
    • Start IV fluids
    • Rapid sequence induction (RSI)
    • General anaesthesia with Propofol
• Post-seizure care
  • Admit to the ICU
  • Consult neurology
  • EEG monitoring
  • Comprehensive physical examination
  • Investigate for possible cause (if the patient has no history of seizure)
• Complications to watch out for post-status epilepticus
  • Rhabdomyolysis (due to muscle contractions and trauma)
  • Aspirtation pneumonitis
  • Arrhythmia