Status Epilepticus

Definition:

• • Continuous sz activity >30 min, or

  • Recurrent sz, without return of normal conciousness between sz.

    • Practically any sz. activity >5 min should be treated as status epilepticus.

  • Nonconvulsive status epilepticus: Status epilepticus with EEG seizures with clinically absent or subtle motor activity and impairment or loss of consciousness.

Management:

• • Place Pt. in semiprone position to decrease risk of aspiration.

  • ABC - airway, BVM,100% O2, suction at bedside, intubation kit, pulse ox, VS, accucheck, ABG, IV, NGT.

  • Endotracheal intubation if seizure is prolonged.

  • Labs: CBC, CCP, LFTs, antiepileptic drug levels, UA, UDS, SDS, ETOH.

  • IV access, start with normal saline only.

  • CT, EEG, EKG

  • Tx:

  • Lorazepam 0.1 mg/kg at 2mg IVP in 2 min. Successive 2 - 4 mg IV pushes until a max dose of 0.1 mg/kg.

  • Or Diazepam 0.2 mg/kg at 5 mg/min. Successive 5 - 10 mg IVP.

  • If no IV, rectal diazepam, 0.5 mg/kg.

  • Fosphenytoin 20 mg/kg PE IV @ maximum rate 150 mg/min. If not available use:

    • Phenytoin,15 - 20 mg/kg, in dextrose free sol, at a rate of 1mg/kg/min to a max of 50 mg/min (monitor BP and cardiac rhythm). Use fosphenytoin - less risk of hypotension.

    • Check with Nursing staff if the floor protocol allows them to give IVP.

    • ECG - check for heart blocks. Phenytoin and Fosphenytoin are C/I in heart blocks.

  • If sz contd...

  • Additional Fosphenytoin 10 mg/kg IV

    • OR

  • Valproate 30 mg/kg IV x 15 min.

    • OR

  • Rocuronium 1 mg/kg +/- propofol or etomidate

  • Intubate, start continuous EEG monitoring:

  • Midazolam 0.2 mg/kg IV bolus then 0.1 - 0.6 mg/kg/hr, induces less hypotension and cardioresp. depression and can be easily titrate; however tachyphylaxis is a problem

    • OR

  • Propofol, 1 - 5 mg/kg IV load, then infusion at 2 mg/kg/hr (30 mcg/kg/min).

  • Pentobarbital 5 mg/kg load at 50 mg/min, followed by infusion of 1 mg/kg/he

  • Titrate above meds to seizure suppression or EEG background suppression.

Supportive therapy:

• • Seizure and Fall Precautions

  • Thiamine 100 mg, IV

  • D50%, 50 ml with thiamine, 100 mg IVP.

  • ChecK urine myoglobin for rhabdomyolysis

  • Treat hyperthermia (40 C) with a cooling blanket, antipyretics.

• • **potassium d/o do not result in sz.

  • -Dilantin 300 mg IVP now, or IVPB in 1 hr in NS. No dextrose sol.

  • 2 hrs later, 300 mg IVPB,

  • 2 hrs later, 300 mg IVPB,

  • 100 mg IVBP q8h