8 Treatment of Status Epilepticus in Adults
Abstract
Status epilepticus is a neurologic emergency that requires immediate evaluation and treatment in order to prevent significant morbidity and mortality. Seizures can present in many different ways, and therefore status epilepticus can be varied in its presentation, as well (i.e. convulsive, nonconvulsive, focal motor, myoclonic). Status epilepticus can become refractory; timely recognition and treatment is necessary to avoid the refractory state/neurologic damage that can occur with prolonged status epilepticus. Here, we will define status epilepticus and detail its management.
Keywords: status epilepticus, status, seizure(s), convulsive, nonconvulsive, refractory status
8.1 Overview and Definitions
Status epilepticus (SE) is a neurologic emergency. This chapter will address the evaluation and management of a seizing patient.
• Seizures may be focal (starting in one part of the brain) or generalized (starting in the whole brain at once)
◦ Focal seizures may impair consciousness or may occur without impaired consciousness
◦ Generalized seizures will always cause impaired consciousness
• Seizures may consist of tonic (stiffening) and clonic (rhythmic jerking) phases, but may also consist of staring, nonresponsiveness, and automatisms (unconscious movements)
There are two types of SE: convulsive SE (CSE) and nonconvulsive SE (NCSE)
• Clinical presentation:
◦ CSE: Rhythmic jerking of the extremities, impairment in mental status, and may have postictal focal neurologic deficits1
◦ NCSE: Subtle and variable semiology (may have positive or negative symptoms)1,2
• SE definitions were applied generally to CSE and NCSE in the past (refer to the points below). But now the definition of NCSE is evolving as continuous EEG monitoring has become more readily available and we can learn more about it (see below in NCSE section for definitions).
• SE is defined by the Neurocritical Care Society Status Epilepticus guidelines as:
◦ Continuous clinical and/or electrographic seizure activity of 5 minutes or more1
◦ Recurrent seizure activity without a return to baseline between seizures1
• Epidemiology:
◦ 50,000 to 150,000 SE cases per year are reported in the United States3
◦ Up to 30% mortality in adults3
• Pathophysiology
◦ SE occurs due to the failure of mechanisms that terminate seizures or initiation of mechanisms that lead to prolonged seizures4
◦ There is a decrease in inhibitory receptors and an increase in excitatory receptors5,6
◦ Key timepoints as per the ILAE Task Force on Classification of Status Epilepticus4:
– t1: when seizures are likely to be prolonged and become continuous
►Tonic-clonic: 5 minutes
►Focal SE with impaired consciousness: 10 minutes
►Absence: 10 to 15 minutes
– t2: when seizures can cause long-term consequences
►Tonic-clonic: 30 minutes
►Focal SE with impaired consciousness: > 60 minutes
►Absence: unknown
8.2 Convulsive Status Epilepticus Management
• Two main CSE treatment guidelines
◦ Neurocritical Care Society1
◦ American Epilepsy Society3
◦ See ▶ Fig. 8.1 for timeline and medication doses3
• Initial SE management (the below management is based on the NCS and AES guidelines in addition to our local institutional practice)1,2,3
◦ Evaluate and secure adequate airway, breathing, and circulation (ABCs)
◦ Obtain intravenous (IV) access
◦ Check finger-stick glucose
– If glucose < 60 mg/dL, give thiamine 100 mg IV × 1, then 50 mg D50 IV
◦ Monitor SpO2, blood pressure, heart rate, and rhythm as vital signs may become unstable
◦ Treat hyperthermia
◦ Obtain labs: CBC, CMP, ABG, PT, INR, aPTT, Ca2 +, Mg2 +, PO4–2, troponin, HCG (if appropriate), ammonia (if appropriate)
◦ Check toxicology screen
◦ Check antiepileptic drug (AED) levels (if appropriate)
◦ Obtain computed tomography (CT) of the head to evaluate for structural lesion if no history of seizures
◦ Consider lumbar puncture and/or antibiotics if there is clinical suspicion of infection
◦ Begin continuous electroencephalography (cEEG) if appropriate; considering the indications outlined by the consensus statement by American Clinical Neurophysiology Society (ACNS)2
– Electroencephalography (EEG) is required for the diagnosis of nonconvulsive seizures and NCSE
►CSE may transition to NCSE; cEEG should be used in patients who do not return to baseline despite therapy
– EEG is required for the assessment of efficacy of continuous IV therapy in SE
– cEEG should be continued until patient is seizure free for at least 24 hours
• Initial medical therapy
◦ Benzodiazepines1,3 should be administered in parallel with the initial management steps listed above
– IV Lorazepam 2 to 4 mg at a time for up to 0.1 mg/kg total dose
– IM Midazolam (especially in prehospital8
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