Status epilepticus Dr Karen Goodfellow

Definition Seizure lasting >30 min or Repeated seizures without intervening consciousness

Differential diagnosis Epilepsy stopping treatment; illness; alcohol; poor compliance Drug or alcohol withdrawal Overdose tricyclics, phenothiazines, amphetamines Hypoxia CVA, SAH Infection Metabolic hypoglycaemia, deranged Ca, Mg, Na, thyroxine, urea, bilirubin Pseudo-seizures Consider pregnancy

Investigations After treatment Bloods Consider Glucose, ABG, U&E, Ca, FBC, LFT, Mg Consider Anticonvulsant levels, toxicology screen, LP, cultures, EEG, CT, CO level

Management Maintain airway & recovery position O2 and suction IV access large bore Monitoring Consider Thiamine 250mg IV IV glucose

Early drug treatments Premonitory stage (pre-hospital) Lorazepam Or Diazepam 10-20mg PR Lorazepam 0.1mg/kg (4mg slow bolus IV (3-4 mins large bore)) Beware respiratory arrest Rpt after 10-20 mins Or Diazepam (not NICE) 10mg slow bolus IV Less long lasting

Established status Phenytoin infusion Maintenance dose (not NICE) 15-18mg/kg IVI Rate of ≤50mg/min SE hypotension; dysrhythmias CI Bradycardia and heart block Maintenance dose (not NICE) 100mg/6-8 hours Phenobarbitone Bolus 10-15mg/kg, rate of 100mg/minute

Refractory status General anaesthetic May be required for paralysis and ventilation if lorazepam +/- phenytoin fails One of: Propofol 1-2mg/kg bolus, then 2-10mg/kg/hr Midazolam 0.1-0.2mg/kg bolus, then 0.05-0.5mg/kg/hr Thiopentone 3-5mg/kg bolus, then 3-5mg/kg/hr Continued for 12-24 hours after last clinical or EEG seizure

Refractory status Diazepam infusion Dexamethasone 100mg in 500ml 5% dextrose 40 ml/hour Dexamethasone 10mg IV Considering cerebral oedema

Long term therapy In parallel with emergency treatment Previous therapy, type of epilepsy, clinical setting Continuation previous therapy Reverse reductions Continuation PO/IV maintenance of phenytoin/phenobarbitone

Non-convulsive status epilepticus Maintenance or reinstatement of usual therapy IV benzodiazepines under EEG control, particularly if diagnosis not established