status epilepticus

-Status Epilepticus

--definition is 5min or not returning to baseline between seizures

--if > 5min, unlikely to stop on its own

--don't forget about NCSE

--EEG is ideal and needed once the patient has stabilized clinically

--Mortality 20% or more; if in ICU; in constant status > 72 hrs, mortality can exceed 60%, even 80%

-Management

--initial abortive

---ideal IV Lorazepam - 2-4mg IV x 1; repeat x 2; Q5min; prepare for airway management; consider less for super frail patients

---ideal IM Midazolam (found to be as effective as IV Lorazepam) - 5-10mg IM, or 5-10mg IV; when going IM, 10mg IM is suggested; again consider the patient; x2 doses; Q5 min; can consider also intra-nasal; less respiratory suppression but again caution with dose and monitor the patient

---note we don't infuse Lorazepam - why? a) precipitation risk b) lactic acidosis due to accumulation of propylene glycol, used a diluent in high-dose IV lorazepam.

---once the dose of BNZ is given, go ahead at the same time with the AED

--then Tx with AEDs

---bring on the AED ASAP

---Urgent control with AED

---Phenytoin 20mg/kg IV load

----check trough level after 24H; consider drug interactions with other agents

---VPA (valproate 25-40mg/kg IV load); suggest go with 40mg/kg IV x 1 - study suggests similar to Phenytoin; don't exceed 2500mg

----check trough level after 24H; consider LFTs, and Ammonia level

---Keppra/Levetiracetam load is 40-60mg/kg over 10min; don't exceed dose of 4.5g IV x 1 first dose; adjust renal clearance

--treatment should be achieved within 60min. Of onset; definitive

--Transfer patient to ICU level 1/2/3

--ESETT trail compared several AED, no difference in agents