Status epilepticus

Definition

Continuous seizure activity lasting 30 minutes or more OR two or more sequential seizures without full recovery of consciousness between, lasting more than 30 minutes

Failure of the normal inhibitory mechanisms in the brain
Repeated seizures can trigger internalization of the post-synaptic GABA receptors

Same as for seizure
MR head
- May see changes related to the area of seizure
- May resolve if patient survives

Emergent, same as for seizure
- ABCs
- Positioning to prevent aspiration, suffocation, and physical injury
- Oral or nasal airway if possible, if prolonged
- Oxygen
- Cardiac, BP, and temperature monitoring
- IV line, send bloodwork
  - CBC, lytes, BUN, Cr, glucose, tox screen, antiepileptic drug levels
- STAT capillary glucose
Treat medically if lasts longer than five minutes or two seizures without return to baseline
- First, treat with benzodiazepine
  - Prefer intravenous to intramuscular
  - Midazolam 10mg IM or buccal
  - Lorazepam 4mg IV
  - Diazepam 10mg IV
  - Repeat in 10minutes
- If benzodiazepines fail, step up to phenytoin
  - Phenytoin 15-20mg/kg given at 50mg/min (~1g for an adult)
  - Can cause hypotension, cardiac arrhythmias, and purple glove syndrome if given too quickly
- If phenytoin fails, transfer to ICU
  - May require more drugs
    - Propafol infusion
    - Midazolam infusion
    - Phenobarbitolf
  - May require intubation
  - May require continuous EEG monitoring
    - May progress to non-convulsive status epilepticus
    - May require paralysis for intubation
    - Can use to monitor medication effects
    - Can identify if seizures are focal
- Investigations
  - Labs, EEG, CT or MRI as per seizures
Late management
- EEG to ensure not in non-convulsive status epilepticus
- Be careful discontinuing the medication that terminated the seizures, as this may trigger recurrence