Status epilepticus

Status Epilepticus Traditionally, SE is defined as continuous or repetitive seizure activity persisting for at least 30 minutes without recovery of consciousness between attacks. For all practical purposes, a patient should be considered to be in SE if a seizure persists for more than 5 minutes.

Status Epilepticus classification Generalized convulsive status epilepticus Non convulsive status epilepticus Focal motor status epilepticus

Epidemiology and Risk Factor 100,000 to 150,000 patients per year in the United States are diagnosed with SE. Approximately one half of the cases occur in young children, but the risk in adults older than 60 years of age is high. The published incidence of SE usually under estimate NCSE.

Status epilepticus occurs in : in patients who sustain an acute process that affects the brain, such as metabolic disturbances, hypoxia, CNS infection, head trauma, or drug intoxication 1 in patients with epilepsy experiencing an exacerbation of seizures, often as a result of abrupt reduction in antiepileptic medication; 2 as a first unprovoked seizure, often heralding the onset of epilepsy. 3

Etiology of status epilepticus in adult

Status epilepticus in pediatrics Convulsive status epilepticus is the most common neurological emergency in childhood. Prolonged febrile sizeurs is the most common cause. Low morbidity and mortality. The general principle of management is the same as adult.

Causes of first episode of convulsive status epilepticus in children

Management of SE Rapidity of treatment is important. Therapeutic intervention are most effective when started early and efficacy decrease significantly with increasing seizures duration. Initial step include basic life support, focused history, initiating IV access, laboratory studies and benzodiazepine.

BLS Give oxygen. Stabilize airway, breathing and circulation. IV access and ECG monitoring. history Prior history of epilepsy, alcohol or drug use or acute neurological insult. Description of seizure onset from a witness. Benzodia zepine IV lorazepam 4mg over 2 min. Rectal, nasal or buccal benzodiazpine should be given if any delay will occur in obtaining IV accsee.

Lab U&E, Mg, Ca, Phos, CBC, LFT, AED level, ABG, trpnonin, toxicology screen ( urine & blood), glucose. Persistent Seizures Phenytoin 15 mg /kg at 50 mg /min or fosphenytoin. BP and ECG monitoring. ICU If sizeurs persist following option can de done under intensive care monitoring:

Load with 0.2mg/kg repeat boluses every 5 min. until seizures stop. CIV 0.1mg/kg/hour max rate is 2.9 mg /kg/hr. If still having seizurs add or swith to propofol or pentobarbital. midazolam Load 1mg/kg reboluse every 3 min. max total dose is 10mg/kg. CIV 1 to 15 mg/kg /hr. If still having seizeurs add or swith to midazolam or pentobarbital. Propofol 40mg/kg over 10 min if still seizing add 20mg/kg. If still having seizeurs Valporate

20mg/kg IV at 50mg/min. If still having seizurs shift to CIV midazolam,propofol or pentobarbital Phenobarbital If sizeurs presist more than 60 min

Refractory status epilepticus CIV pentobarbital. Load: 5 mg/kg at up to 50 mg/min; repeat 5 mg/kg boluses until seizures stop. Initial CIV rate: 1 mg/kg/h. CIV dose range: 0.5 mg/kg/h to 10 mg/kg/h. traditionally titrated to suppression burst on EEG but titrating to seizure suppression is reasonable as well.

Parmacotheray for treatment of status Epilepticus

EEG monitoring EEG is mandatory for correct diagnosis and monitoring response to therapy. Residual electrical seizure activity occur almost in 50% of patient who present with GCSE after cessation of motor activity. Persistent NCSE can prevent recovery and add to morbidty.

Complication of SE Hippocampal complex, amygedla, thalmus are vulnerable to SE which lead to permanent impairment in memory, affect and cognetion. Mortality range between 3% to 20%, children have lower mortality rate than adult.

Future Directions IV lorezpam is an excellent first line treatment but step after that are less clear and require and require randomized trials. Neuroprotection is a new focus for research, some newer AEDs have neuroprotictive property that may prevent neuronal injury,other neuroprotictive methods are hypothetmia, antioxidants and erythropoietin.

Future Directions Development of reliable neuronal injury marker will be quite helpful in determining which patient require aggressive treatment and to predict outcome. Neuron specific enolase which is elevated in patient with SE and correlate with duration and outcome is under investigation to be used as a marker.

Thank you Hind Alnajashi