Treatment of Status Epilepticus in Adults

8 Treatment of Status Epilepticus in Adults

James Park, Alan Wang, Andres Fernandez, and Sara Hefton

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

May consider magnetic resonance imaging (MRI) of brain with and without contrast after seizures are controlled

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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Aug 7, 2022 | Posted by in NEUROSURGERY | Comments Off on Treatment of Status Epilepticus in Adults

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