Status Epilepticus

Convulsive status epilepticus (CSE) is one of the most common medical neurologic emergencies and continues to be associated with significant mortality and morbidity. In people with epilepsy, CSE is often provoked by withdrawal or reduction of antiepileptic drugs. However, more than 50% of people with CSE have never had an epileptic seizure before. The most common causes in children are febrile seizures, meningitis, and preexisting neurologic disorders such as cerebral palsy. In adults, CSE is often caused by cerebrovascular insults, cerebral anoxia, alcohol withdrawal, drug abuse, and tumors. To minimize the risk of an adverse outcome, treatment should be initiated as soon as possible. Because most seizures begin in the community, medications such as rectal diazepam should be carried by emergency medical technicians, administered in the community setting, and the patient transported urgently to the nearest emergency department. In the hospital setting, an airway should be immediately provided and maintained. Cardiorespiratory status and other vital functions should be assessed and support given if necessary. Blood samples should be drawn for analysis and an infusion of normal saline should be started. The initial in hospital, treatment is usually a benzodiazepine, such as lorazepam, administered intravenously. If benzodiazepines fail to terminate the seizure, then phenytoin or phenobarbitone may be administered. If seizures remain uncontrolled, then general anesthesia and artificial ventilation may be required.

Nonconvulsive status epilepticus (NCSE) refers to the situation in which there is EEG evidence of epileptiform abnormalities that are continuous in the absence of obvious clinical motor manifestations. NCSE in patients with epilepsy often occurs in the context of absence epilepsy and focal seizures, particularly those arising in the temporal lobe. Patients with confusion may have NCSE, and patients admitted to an intensive care unit may also develop NCSE. Because NCSE may worsen the prognosis of the underlying disorder, treatment of the status is recommended. However, there is debate on whether aggressive therapy with anesthetic agents is warranted. Epilepsia partialis continua refers to the situation in which there is continuous focal motor activity that may last months to years. The most common cause is Rasmussen encephalitis.

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