1. Status epilepticus
Dr Karen Goodfellow

2. Definition Seizure lasting >30 minor
Repeated seizures without intervening consciousness

3. 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

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

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

6. 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 mins Or
Diazepam (not NICE)
10mg slow bolus IV
Less long lasting

7. 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

8. 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
mg/kg bolus, then mg/kg/hr
Thiopentone
3-5mg/kg bolus, then 3-5mg/kg/hr
Continued for hours after last clinical or EEG seizure

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

10. 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

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