Status epilepticus: diagnosis and treatment updates
Status epilepticus may represent an exacerbation of a pre-existing seizure disorder, the initial manifestation of a seizure disorder, or emotion other than a seizure disorder.
Status epilepticus is a common, life-threatening neurological disorder that is essentially an acute, prolonged seizure. Status epilepticus may represent an exacerbation of a pre-existing seizure disorder, the initial manifestation of a seizure disorder, or emotion other than a seizure disorder. In patients with known epilepsy, the most common cause is a change in medication. Most seizures stop spontaneously.
According to the clinical history, partial motor epilepsy is not simply associated with subjective sensory disturbances, including the following:
Paraesthesia or numbness is localized or unilateral.
The focal image changes often characterized by flashing lights.
Obscuring the visual focal point or the colourful illusion focus.
Abdominal distension is atypical.
Checking for status epilepticus includes the following:
Generalized status epilepticus: Typical rhythmic spastic and tonic-clonic activity, impaired consciousness; may rarely manifest as prolonged convulsions.
Status epilepticus due to drug use: needle traces.
Status epilepticus due to tumour damage or brain infection may occur Papillary oedema, lateral neurologic features.
Subtle or transitional status epilepticus: Any patient with no improvement in the level of consciousness within 20-30 minutes of cessation of generalized seizure activity.
Associated Injuries in Patients with Convulsions: May include tongue laceration (usually lateral), shoulder dislocation, head trauma, facial trauma.
Complications of status epilepticus are many. Systemic complications include:
Increase body temperature.
Active treatment is required for status epilepticus. Clinicians should not wait for blood test results before administering a loading dose of phenytoin, regardless of whether the patient is already taking phenytoin.
Most patients with epilepsy who are actively treated with benzodiazepines, fosphenytoin, and/or phenobarbital have complete cessation of seizures. If the status epilepticus does not stop, general anaesthesia is indicated.
Medications used in the treatment of status epilepticus include:
Benzodiazepines (eg, lorazepam, diazepam, midazolam): First-line drugs.
Anticonvulsants (eg, phenytoin, fosphenytoin).
Sedatives (eg, phenobarbital, pentobarbital).
Aesthetic (eg, propofol).
Supportive care in patients with status epilepticus includes the following:
Maintain vital signs.
Airway, breathing, circulation (eg, hemodynamic/cardiac monitoring).
Provide respiratory support, intubation, and/or mechanical ventilation if necessary.
Routine neurological evaluation.
Protect from injury, loosen clothing, maintain airway, and deliver oxygen as required.
Place an intravenous line
Both generalized generalized convulsive status epilepticus and mild spasticity must be treated aggressively.
Maintenance of vital signs, including respiratory function, is of great importance. Any signs of respiratory failure should be resolved by endotracheal intubation. Early treatment measures are taken in conjunction with the diagnosis. The treating physician should not wait for a blood test before administering a loading dose of phenytoin. Monitoring should be performed regardless of whether the patient has received phenytoin or not. It is assumed that the patient is not compliant with treatment as this is the most common cause of status epilepticus in patients with known epilepsy.
Supportive care, including ABC, must be addressed in the pre-hospital setting. If seizures do not stop within 4-5 minutes or if the patient continues to have seizures by the time paramedics arrive, prompt anticonvulsant medication may be necessary.
Due to refrigeration requirements and the occasional use of most anticonvulsants, diazepam (Valium) is often the only anticonvulsant available prior to admission. Diazepam can be given intravenously or rectally.
Establish venous access, ideally within a large vein. Intravenous administration is the preferred route of anticonvulsant administration because it allows for faster therapeutic concentrations to be achieved. Initiate other cardiac and hemodynamic monitoring.
Administer 50 ml of 50% dextrose intravenously and 100 mg of thiamine. If seizures don't stop within 4-5 minutes, start taking anticonvulsants. If history has confirmed status epilepticus, treatment should begin immediately. In some cases of potential opiate toxicity, consider adding naloxone 0.4-2.0 mg to the intravenous dextrose.
Administer diazepam (0.15 mg/kg) or lorazepam (0.1 mg/kg) intravenously over 5 minutes, followed by fosphenytoin. Fosphenytoin is administered at a dose of 15-20 mg phenytoin equivalent [PE]/kg, at a rate not to exceed 150 mg phenytoin/min). The dose of phenytoin is 18-20 mg/kg, at a rate not exceeding 50 mg/min).
Never mix phenytoin with 5% dextrose solution; put it in a common saline solution to minimize the risk of crystal precipitation.