| Status Epilepticus (Epilepsy)
| Non Convulsive Status Epilepticus
| Coma management
| Epilepsy - General Management
| First Seizure
| Epilepsy in Pregnancy
| Febrile seizures
|Initial Status Epilepticus Management Summary|
- Seizure Persisting 5 mins+/Recurring Seizure,
- Check time. ABC, O2, Check glucose, Recovery position
- Basic obs. Temp/HR/BP/Sats. If GCS < 9 ask for anaesthetic review
- IV Access. Send FBC, U&E, LFT, Ca, Glucose, Anticonvulsant levels
- Treat Hypoglycaemia 100 ml 10% Glucose or 1 mg IM Glucagon
- If alcohol/malnourished then IV Pabrinex 2 pairs IV over 10 mins
- Give Benzodiazepine(At all times be ready to manage respiratory depression)
- Lorazepam 4 mg slow IV (repeat after 5 mins if needed)
- Midazolam 10 mg buccal(repeat after 5 mins if needed)
- Midazolam 10 mg IM(repeat after 5 mins if needed)
- Continues seziure after 15 mins (ITU consult)
- IV Levetiracetam 60mg/kg, max 4500mg (in 100ml NS over 10 minutes).
- IV Phenytoin 20mg/kg, max 2g (rate 50mg/min, 25mg/min elderly, cardiac. Give undiluted)
- IV Valproate 40mg/kg, max 3000mg in 100ml NS over 5 mins
- Consider brain imaging/LP/CSF once stable and ITU
- May need intubated and ventilated
- Generalised Tonic-clonic usually with loss of consciousness.
- Most seizures last less than 5 minutes and need only supportive treatment and no benzodiazepines.
- Watch out for non convulsive status: reduced GCS + eye flickers, minor focal motor seizures.
- Mimics hypoactive delirium. Lorazepam. Confirm with EEG
Complications of seizure and sedation
- Injury, Lateral tongue bite, Urine/Faecal Incontinence
- Aspiration pneumonia, Respiratory failure, Hypoxic brain injury, Non-convulsive status (Get EEG)
- Venous thromboembolism
Investigations (depends on circumstances)
- FBC, U&E, CRP, Ca, Mg, Glucose
- CT Head, LP, EEG. Later MRI if first fit or encephalitis
- Pregnancy test in all fertile female
- Check Anticonvulsant levels
- Toxicology: 5 ml serum + 50 ml Urine
EEG showing SE. In practice rarely possible to monitor acutely
Consider Causes: Known Epilepsy
- Change in meds, Forget meds, Erratic life
- Alcohol, infection, Stress, Fatigue, Menstruation
Consider Causes: New Seizures
- Inherited/Familial, Dementia, Old Stroke
- Previous Neurosurgery, tumour, bleed, abscess
- Meningitis/Encephalitis, Head injury, Eclampsia
- Drug withdrawal or overdose (Mefenamic acid)
- Other considerations: Pseudo seizures
- 1st stage Treatment Options 0-10 mins
- ABC, Secure airway, High flow O2, Continuous ECG, SaO2 monitoring.
- Recovery position, padded bed +/- Nasopharyngeal airway
- IV Access. Check fingerstick BM + IV 100 ml 20% Glucose if BM < 4.
- Coma: IF GCS < 9 then anaesthetic review for airways management and HDU/ITU bed.
- Alcoholism or malnourished give IV Pabrinex (2 ampoules TDS 2 days) and then Thiamine 250 mg IV
- Treat severe acidosis
- Choice of Benzodiazepine
- Lorazepam 4 mg (0.1 mg/kg) stat IV. Can repeat at 10 mins OR
- Midazolam 10 mg stat Buccal or IM
- Diazepam 10 mg PR which may be repeated
- Diazepam 10 mg slowly IV which may be repeated
- At all times be ready to manage respiratory depression
- Consider Anticonvulsant
- Phenytoin 20 mg/kg stat slow IV at 50 mg/min on cardiac monitor. Then consider staring Phenytoin 100 mg 8-hrly PO/IV or another anticonvulsant when situation resolves. Max dose is 2000 mg. Do not give loading dose if patient is already on Phenytoin.
- Levetiracetam 60 mg/kg over 15 mins. Max 4500 mg then 500-1000 mg BD if not on it already. Other dosing regimens say 60 mg/min follow local guidance
- Valproate 30 mg/kg over 15 mins IV Max 3000 mg. May be preferred if there is a history of myoclonic epilepsy. Not if pregnant/mitochondrial disease. Ongoing dose 1000 mg BD if not on it already
- Continuing seizures at 30 mins
- Consider ITU referral. Paralysis and sedation and intubation. EEG monitoring. Propofol, Midazolam or thiopental sodium. Speak with neurology on call.
- If CNS infection suspected: consider Lumbar puncture and Aciclovir 10 mg/kg 8-hourly IV and Cefotaxime IV See Meningitis and Encephalitis
- Pregnancy Eclampsia: Magnesium 4 g IV bolus
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