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MANAGEMENT OF CONVULSIVE STATUS EPILEPTICUS Convulsive (tonic-clonic) status epilepticus is seizures occurring continuously or recurrently for at least 30 minutes

s without recovery. It is a medical emergency there is high risk of cerebral damage and death if seizures are not controlled within 60-90 min. Convulsive status epilepticus may occur in patients with known epilepsy, be the first presentation of epilepsy (12% of patients) or occur de novo as a manifestation of new cerebral lesion or acute metabolic insult. General therapeutic/diagnostic measures must be taken in parallel with emergency drug treatment but the latter must always take priority.

EMERGENCY DRUG TREATMENT Premonitory stage

Aggressive treatment of escalating seizures (increasing frequency/severity) may prevent evolution into status. Benzodiazepines are 1st choice of therapy. Treatment options: Patient alert between seizures oral Clobazam 10-20mg/day for 2-3 days Patient drowsy between seizures parenteral benzodiazepine Rectal diazepam 10-20mg (can be given in community) General measures IV lorazepam 4mg bolus rate of injection not critical In known epilepsy check AED IV diazepam 10-20mg (rate 5mg/min) compliance, IM midazolam (10mg) resume usual AED as soon as Each can be repeated after 30 min if status still threatens possible, or consider change of AED. Diagnose cause of seizures in de

Early status epilepticus ( 0 30 min) Lorazepam 4mg IV bolus, repeated once after 15 min if necessary (stops status in 80% of patients) Established status epilepticus ( 30 60/90 min) If status has continued for 30 min in spite of early treatment one of the following therapies should be given (intensive care facilities are desirable at this stage): Phenytoin IV 18mg/kg at a rate of 50mg/min (average adult dose 1000 1400mg over 20-30 min) Fosphenytoin (Pro-Epanutin) 18mg/kg at a rate of 100mg/min (average adult dose 1000 1400mg over 12-13 min, can be given IM) (ECG monitoring essential during administration of fosphenytoin and phenytoin) Phenobarbitone 10mg/kg IV infusion at a rate 100mg/min (average adult dose 700mg over 7 min) Refractory status epilepticus (after 60 min) If status epilepticus cannot be controlled within 60 min, full anaesthesia in an intensive therapy unit is required.

Further attempts to control the status with AEDs in sub-anaesthetic doses should not be made; they are unlikely to be effective and increase the risk of cerebral damage. Choices of drugs include IV thiopentone or propofol EEG monitoring is required (seizure activity at this stage may be only electrographic) Titrate the dose of an anaesthetic to achieve burst suppression pattern on EEG The anaesthesia can be lightened after 12 hours Patient monitored for clinical and electrographic evidence of seizure recurrence, repeated anaesthesia if required. General measures 0-60 min of status Standard first aid, administer 02, resuscitate Venous access large veins Bloods for FBC, U+E, LFTs, glucose, Ca2+, Mg2+, antiepileptic drug levels, arterial blood gases, urine for toxicology Administer IV glucose (50ml of 50% solution) and/or thiamine 250mg (10ml High Potency Pabrinex IV over 10 min) if appropriate Monitor ACG, BP, temperature, pulse oximetry Treat complications (hypotension, respiratory depression, hypothermia, acidosis) Obtain concise history, establish aetiology All de novo cases CT brain and CSF examination if CT normal Known epilepsy CT and CSF examination if no recovery with treatment within 2 hours ?Recent AED withdrawal or reduction re-establish AED as soon as possible (by IV injection if appropriate) Initiate long-term maintenance AED therapy, in tandem with emergency therapy (choice depends on clinical setting and previous drug history) ADDENDA CONVULSIVE STATUS EPILEPTICUS Table 1 Causes of convulsive status epilepticus Previous history of epilepsy Presenting for the first time with status Cerebrovascular disease 20% Cerebral tumour 16% Intracranial infection 15% Other acute event 14% Cerebral trauma 12% Acute metabolic disturbances 12% Cause not found 11%

Withdrawal of AED Alcohol (or withdrawal of) Drug overdose If no obvious provoking factor consider: Cerebrovascular disease 19% Cerebral trauma 17% Cerebral tumour 10%

Intracranial infection 6% Acute metabolic disturbances 5% Other acute event 3% Cause not found 40%

Table 2 properties of AEDs used in tonic-clonic status epilepticus


Lorazepam Adult IV dose Maximal rate of administratio n Time to stop status (min) Effective duration of action (hours) Potential side effects -depressed consciousness -respiratory depression -cardiac arrhythmia -hypotension Infrequent 4-8mg Not important; (some recommen d 2mg/min) 6-10 12-24 Diazepam 10-20mg 5mg/min Fosphenytoi n 18mg/kg 100mg/min Phenytoin 18mg/kg 50mg/min Phenobarbito ne 10mg/kg 100mg/min

1-3 0.25-0.5

10-20 24

10-30 24

20-30 >48

Several hours Occasional None

10-30 min Occasional None

None Infrequent In patients with cardiac disease Occasional

None Infrequent In patients with cardiac disease Occasional

Several days Occasional None

Infrequent

Infrequent