Status Epilepticus

Status Epilepticus

Background

  • Either a single seizure >5 minutes or 2 seizures occurring without a return to baseline in between [previous guidelines used 30 minutes as a marker, but this has been updated]
  • Differentiating convulsive seizures from non-epileptic events (“pseudoseizure”):
    • Features that suggest non-epileptic/psychogenic event include moaning or talking throughout the event, “no-no” head shake, repetitive movements of opposing muscle groups, very arrhythmic or purposeful-looking movements, or seizures that have been ongoing for “hours”

 

Evaluation

  • Fingerstick glucose, BMP/CBC, and UDS
  • Consult Neurology
  • EEG (start with 2hr) to determine if it is seizure or not and for titration of medications
  • Consider a non-contrasted head CT; MRI cannot be obtained while EEG is attached
  • Up to half of pts presenting in status epilepticus have no history of seizure, so they need urgent head imaging, consideration for lumbar puncture, infectious and toxic workup, tox screen, and sometimes rheumatologic or paraneoplastic workup

 

Management

  • ABCs! Start with benzos: 2 mg lorazepam IV every minute or 5 mg of diazepam IV every minute (they do take a few minutes to work, though) up to 0.1 mg/kg of lorazepam
  • After 2 rounds of benzos, would shift to antiepileptics if pt is still in status (neurology should be contacted here if not already):
    • IV fosphenytoin 20 mg/kg
    • IV levetiracetam 30-60 mg/kg (generally 3 grams is good)
    • IV valproic acid 30 mg/kg
  • If still seizing at this point, the pt will likely need be intubated
  • These pts MUST be placed on EEG if they get paralyzed or sedated because convulsive status often continues as nonconvulsive status, which still damages the brain!
    • If still seizing, pts should be on midazolam, propofol or barbiturate infusions for burst suppression
    • Focal seizures, such as arm or face twitching with retained awareness do not always need to be treated to the point of initiating coma