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Status Epilepticus (Epilepsy/Seizure)

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Management of status: Check time of seizure onset if known if T less than 5 mins
0-5 mins: Recovery position, observe, oxygen. Check ABC and blood glucose If seizure has settled then observe and manage as normal General Thoughts if fitting < 5 mins Known epilepsy. Drugs taken e.g. alcohol and alcohol withdrawal ABC, O₂, Check glucose. Recovery position, Nasopharyngeal airway 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 Alcohol/malnourished/hyperemesis:IV Pabrinex 2 pairs IV over 10 mins Time from onset > 5 mins: Give Benzodiazepine (S/E resp depression); choices are Lorazepam 4 mg (0.1 mg/kg) slow IV Midazolam 10 mg Buccal Midazolam 10 mg IM Diazepam 10 mg Rectal Pregnancy Eclampsia: Magnesium 4 g IV bolus Observe for and manage respiratory depression Time from onset 10-20 mins: Repeat Benzodiazepine dose if not already done so. Watch for resp depression. Monitor ABCs. Choices are Lorazepam 4 mg (0.1 mg/kg) slow IV Midazolam 10 mg Buccal Midazolam 10 mg IM Diazepam 10 mg Rectal Observe for and manage respiratory depression Time from onset > 20 mins consider one of these and alert HDU/ITU 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). Needs cardiac monitor IV Valproate 40mg/kg, max 3000mg in 100ml NS over 5 mins. Avoid if pregnant, mitochondrial disease, or advanced liver disease Time from onset > 30 mins consider one of these Consider ITU referral. Paralysis and sedation and intubation. EEG monitoring. Propofol, Midazolam or thiopental sodium. CNS infection consider Lumbar puncture IV Aciclovir 10 mg/kg 8-hourly IV if HSV encephalitis suspected IV Cefotaxime IV if Bacterial Meningitis suspected IV Quinine. Always consider Malaria but very rare IV Dexamethasone 10 mg IV if cerebral oedema, inflammatory CNS condition, and infection excluded IV Mannitol if Raised ICP and coning suspected Post stabilisation and further management Consider brain imaging/LP/CSF once stable and ITU May need intubated and ventilated, so involve ITU early

Management of status: Check time of seizure onset if known if T less than 5 mins

0-5 mins: Recovery position, observe, oxygen. Check ABC and blood glucose
If seizure has settled then observe and manage as normal

General Thoughts if fitting < 5 mins

Known epilepsy. Drugs taken e.g. alcohol and alcohol withdrawal
ABC, O₂, Check glucose. Recovery position, Nasopharyngeal airway
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
Alcohol/malnourished/hyperemesis:IV Pabrinex 2 pairs IV over 10 mins

Time from onset > 5 mins: Give Benzodiazepine (S/E resp depression); choices are

Lorazepam 4 mg (0.1 mg/kg) slow IV
Midazolam 10 mg Buccal
Midazolam 10 mg IM
Diazepam 10 mg Rectal
Pregnancy Eclampsia: Magnesium 4 g IV bolus
Observe for and manage respiratory depression

Time from onset 10-20 mins: Repeat Benzodiazepine dose if not already done so. Watch for resp depression. Monitor ABCs. Choices are

Lorazepam 4 mg (0.1 mg/kg) slow IV
Midazolam 10 mg Buccal
Midazolam 10 mg IM
Diazepam 10 mg Rectal
Observe for and manage respiratory depression

Time from onset > 20 mins consider one of these and alert HDU/ITU

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). Needs cardiac monitor
IV Valproate 40mg/kg, max 3000mg in 100ml NS over 5 mins. Avoid if pregnant, mitochondrial disease, or advanced liver disease

Time from onset > 30 mins consider one of these

Consider ITU referral. Paralysis and sedation and intubation. EEG monitoring.
Propofol, Midazolam or thiopental sodium.
CNS infection consider Lumbar puncture
IV Aciclovir 10 mg/kg 8-hourly IV if HSV encephalitis suspected
IV Cefotaxime IV if Bacterial Meningitis suspected
IV Quinine. Always consider Malaria but very rare
IV Dexamethasone 10 mg IV if cerebral oedema, inflammatory CNS condition, and infection excluded
IV Mannitol if Raised ICP and coning suspected

Post stabilisation and further management

Consider brain imaging/LP/CSF once stable and ITU
May need intubated and ventilated, so involve ITU early

Clinical

Generalised Tonic-clonic usually with loss of consciousness.
Most seizures last less than 5 minutes. Need supportive treatment only.
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

Management

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

Makindo Medical Notes.com

Status Epilepticus (Epilepsy/Seizure)

General Thoughts if fitting < 5 mins

Time from onset > 5 mins: Give Benzodiazepine (S/E resp depression); choices are

Time from onset 10-20 mins: Repeat Benzodiazepine dose if not already done so. Watch for resp depression. Monitor ABCs. Choices are

Time from onset > 20 mins consider one of these and alert HDU/ITU

Time from onset > 30 mins consider one of these

Post stabilisation and further management

Clinical

Complications of seizure and sedation

Investigations (depends on circumstances)

Consider Causes: Known Epilepsy

Consider Causes: New Seizures

Management

Walton Centre Proforma Link here

References