Presentation and buzz words:
Not back to baseline, not at baseline, fluctuating mental status
Status epilepticus can be convulsive or non-convulsive
ASM = antiseizure medication (or AED = antiepileptic drug)
One liner:
When presenting the one liner, note last seizure date and time.
When you present, note most recent confirmed seizure, which ASMs (and how much) have been administered, and etiology if known.
Diagnose status type:
Generalized (convulsive) status epilepticus: >5 minutes of continuous seizures or ≥2 seizures without return to baseline.
Non-convulsive status epilepticus: >10 minutes of electrographic seizures without clinical correlation or 20% seizure burden in one hour.
Refractory status epilepticus: continues despite benzodiazepine + one first line agent at appropriate dose.
Super-refractory status epilepticus: continues despite anesthetics for >24 hours or comes back once start weaning anesthetics.
Diagnose etiololgy:
Does patient have a previous history of epilepsy?
If so, note compliance, meds and seizure frequency
Look for something which could have lowered seizure threshold
First time seizure?
Was it provoked? Such as hyponatremia or DKA
If unprovoked, patient will need neuroimaging and EEG for baseline
Status epilepticus ICU course/possible complications:
Patients are typically admitted to the ICU for presumed/possible non convulsive status epilepticus (NCSE) in the absence of EEG
Often patients are intubated and sedated due to this concern
EEG will help determine if this is the case
If patient back to baseline before EEG, patient is not in NCSE
If patient in NCSE: we treat based on treatment algorithm and choose antiepileptics/anesthetics based on side effects and differences in mechanism of action.
Complications may happen secondary to ASMs
Important to monitor for drug toxicity
Treatment algorithm for status epilepticus:
Assure patient is maintaining ABCs and has IV access. Check fingerstick glucose.
Phase I: lorazepam (Ativan) or midazolam (Versed). Give repeat dose if no response. Should always be followed by a phase II antiseizure medication (ASM) since benzos have a short half-life.
Phase II: pick an ASM.
Keppra (levetiracetam) is a neurology favorite due to good side effect profile (agitation only compared to others). Make sure it's renally dosed.
Depakote (valproate) is not good for liver patients (check ammonia and LFTs, can also drop platelets). Can cause pancreatitis and has multiple drug interactions.
Dilantin (fosphenytoin) can cause hypotension and life-threatening arrhythmias and has multiple drug interactions.
Phase III: anesthetize and intubate to try to "reset" the brain. There are different options:
Propofol drip
Midazolam drip
Ketamine drip
Pentobarbital drip induces a coma. Reserved for severe refractory cases because it has many serious side effects.
Past the acute phase:
Once the anesthetics are on board, this is your time to optimize your ASM to hopefully have them on board when you start to wean the anesthetics.
When you add additional ASMs, think of different mechanisms of action to target different receptors. Also think of side effect profile depending on your patient.
#Status Epilepticus Plan Guidance:
Obtain a thorough seizure history.
Do they have known epilepsy? Family history? Known etiology? When were they diagnosed?
When was their last seizure? How often do they have breakthrough seizures?
What is the semiology of their seizure? Any triggers?
Obtain a thorough seizure medication history.
If any of the meds didn't work, what happened? This is very valuable information that it doesn't always get documented!
Obtain a thorough history focusing on anything that may have lowered the seizure threshold.
Compliant with medications? Any recent medication changes, illnesses or infections, trauma, drug/alcohol use?
If they are non compliant, why? Is there something we can do to get them to be compliant?
Check serum ASM levels for depakote (aim for level 50-100), dilantin (aim for level 10-15 or 15-20 if refractory status).
Dilantin (phenytoin) level must always be checked with an albumin level as it is protein bound. Correction calculator.
Check fingerstick glucose, CBC, CMP, lactic acid, CK, ABG, toxicology screen.
Glucose, calcium, sodium, magnesium derangements are frequent offenders.
Make sure we have ruled out infection as it's one of the most common culprits.
UA, CXR. Consider other infectious work up depending on your patient presentation and history.
Evaluate for structural abnormalities or acute insults: order neuroimaging studies needed.
All new onset unprovoked seizures will need neuroimaging at some point during their hospital stay, may be done once downgraded from neuroICU.
New onset provoked seizures do not need more neuroimaging or more work up.
Once patient on 4-5+ ASMs, consider non-pharmacologic agents
Address need for daily cEEG
Indications for ordering an EEG:
Clinical paroxysmal events suspected to be seizures.
Prognostication in TBI, SAH, hypoxic brain injury: the EEG tells us a lot - if the brain is reactive to the environment, degree of slowing, sleep pattern, symmetry, etc.
Anybody with encephalopathy that we cannot explain.
Fluctuating mental status: must rule out non-convulsive status epilepticus as cause of fluctuations.
Inadequate neuro exam in paralyzed/sedated SE patient: this helps us make sure to avoid medication toxicity once at goal .
Post-convulsive patient who is now following commands consistently does not need cEEG.
Continue cEEG if:
You have not captured an episode you were suspicious about.
Ongoing prognostication.
Evidence of inter-ictal continuum with risk for evolving to seizures/status.
Ongoing uptitration of paralytics/sedatives.
Consider discontinuing cEEG if:
Clinical paroxysmal events suspected to be seizures were captured and determined to not be seizures.
Done with neuroprognostication.
Negative for NCSE in a patient with encephalopathy or fluctuating mental status.
Paralytics/sedation are discontinued successfully and no longer needed to monitor for toxicity.
24 hours post-cessation of status/last seizure or if patient burst-suppressed for status, 24 hours post successful weaned off of anesthetics.