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Status Epilepticus – Standard Treatment Guidelines


Status Epilepticus – Standard Treatment Guidelines

Status epilepticus (SE) is a state of continuous seizure without return of consciousness. Any seizure type can progress to status epilepticus. Status epilepticus is a serious medical and neurological emergency which requires efficient management as delay is associated with worse outcome. The prognosis depends predominantly on the cause and duration of the SE and is good in rapidly reversible causes. Overall mortality is 15.8 %. Additional 10 to 23% of patients who survived from status epilepticus are left with disability.

Ministry of Health and Family Welfare has come out with the Standard Treatment Guidelines for Status Epilepticus. Following are its major recommendations.

Case definition:

For both situations of care (mentioned below*)

Clinically definition of SE is based on manifestations of continuous seizure activity and incomplete recovery of consciousness between seizures for a ‘particular duration’. The criterion for duration is still ambiguous and evolving issue. For all practical purposes, a patient should be considered in status epilepticus if seizure activity lasting more than 5 minutes as very few single seizures will last this long.

Refractory Status Epilepticus (RSE): Appropriate definition is still not available. RSE is commonly defined as seizure activity that continues after failure of first and second line antiepileptic drug therapy (AED) therapy.

Incidence of The Condition In Our Country

Chin et al in a recent systemic review reported incidence rates of SE between 3.86 to 38 per 100,000 per year in children and 6 to 27 per 100000 per year in adults in Europe. Incidence has bimodal distribution with peaks in children less than a year (135 to 156 per 100000 per year) and elderly (14.6 to 86 per 100000 per year).The annual incidence of Non convulsive status epilepticus (NCSE) is 2.6 and 7.8 per 100000. NCSE was documented in 8 % of all comatose patients without signs of seizure activity. Frequency of refractory status epilepticus in patients with SE ranged from 31 to 44 %.

There is hardly any incidence data available in India. In a recent study NCSE was documented as a cause of altered mental status in 10.5% of comatose patients without signs of seizure activity. The incidence of RSE in SE patients in Indian series ranges between 12 and 19 %.

Differential Diagnosis

Disorders that may mimic seizures are benign conditions like myoclonus, fasciculations, tremors, tics, panic attack, psychogenic seizures and potentially dangerous conditions like basilar artery transient ischemic attack, metabolic encephalopathy and syncope. When doubt regarding diagnosis is present one should always request neurological consultation and electroencephalogram (EEG). Video- EEG monitoring may be useful for detection of ongoing subclinical seizures and should be considered in critically ill patient with unexplained altered mental status.

Optimal Diagnostic Criteria, Investigations, Treatment & Referral Criteria

*Situation 1: At Secondary Hospital/ Non-Metro situation: Optimal Standards of Treatment in Situations where technology and resources are limited

a) Clinical Diagnosis:

SE is best divided into three categories:

Convulsive status epilepticus (CSE)

Non convulsive status epilepticus (NCSE)

Partial status epilepticus (PSE)

CSE is the most common form of SE characterized by rhythmic jerking of the body, limbs, tongue biting and loss of consciousness. With increasing seizure duration the movements may become reduced although generalized electrical activity continues in the brain.

NCSE may be difficult to diagnose and may be more common in the elderly population. Although there is no accepted classification of NCSE, two major types are partial complex –which is subdivided on the basis that whether the patient has underlying epilepsy or is in coma and petit mal.

In partial complex SE stereotypical movements such as lip smacking, chewing or picking at ones’ clothes may occur and alteration of consciousness lasts more than 30 minutes as result of abnormal cortical electrical activity.

Physical examination should look for signs of occult head trauma, substance abuse, fever, meningismus and diabetes. Always check for Medical Alert bracelets or wallet information and try to contact relatives to determine prior medical and seizure history.

b) Basic Investigations

Complete blood count , electrolytes ,Blood urea nitrogen(BUN),serum creatinine,glucose,liver function test

c) Treatment

Initial general management:

  • Assess basic life support
  • Start supplemental oxygen, monitor oxygen saturation
  • Initiate seizure precautions (e.g., padding bed rails)
  • Monitor vital signs and ECG
  • Adequate venous access and liberal hydration should be started with normal saline to prevent dehydration and rhabdomyolysis.
  • Blood pressure should be monitored closely, especially if seizures persist for more than 30 minute
  • Consider thiamine 100 mg IV and dextrose 25-50 g IV if blood glucose is less than 60 mg/dl
  • Treat fever with acetaminophen and icepacks

Initial Antiepileptic drug treatment

  • In the setting of acute brain injury, treatment usually should be initiated after a single self limited seizure. Initial AEDs (viz. Lorazepam and phenytoin) should be given as soon as possible.
  • Management of SE should begin within 5 minutes of seizure activity or after two seizures without full recovery in between.
  • Give IV Lorazepam 0.1 mg/kg IV at 2mg/minIf Lorazepam is not immediately available, diazepam 10-20 mg or midazolam 2-5 mg can be substituted
  • Midazolam given intramuscularly is the promising treatment in prehospital settings
  • Start phenytoin 20 mg/kg IV load at <= 50 mg/min

Referral criteria:

Patients of SE can be considered for transfer to superspeciality center if seizures are not controlled with benzodiazepine and first line antiepileptic drugs or patient has recurrent seizures after initial stabilization.

*Situation 2: At Super Specialty Facility in Metro location where higher-end technology is available

a) Clinical diagnosis

SE is best divided into three categories:

Convulsive status epilepticus (CSE)

Non convulsive status epilepticus (NCSE)

Partial status epilepticus (PSE)

CSE is the most common form of SE characterized by rhythmic jerking of the body, limbs, tongue biting and loss of consciousness. With increasing seizure duration the movements may become reduced although generalized electrical activity continues in the brain.

NCSE may be difficult to diagnose and may be more common in the elderly population. Although there is no accepted classification of NCSE, two major types are partial complex –which is subdivided on the basis that whether the patient has underlying epilepsy or is in coma and petit mal.

In partial complex SE stereotypical movements such as lip smacking, chewing or picking at ones’ clothes may occur and alteration of consciousness lasts more than 30 minutes as result of abnormal cortical electrical activity.

Physical examination should look for signs of occult head trauma, substance abuse, fever, meningismus and diabetes. Always check for Medical Alert bracelets or wallet information and try to contact relatives to determine prior medical and seizure history.

b) Investigation

  • Blood and urine toxicology screen and when indicated pregnancy test and arterial blood gases, serum ammonia level
  • Anticonvulsant medication levels
  • CT or MRI scan and lumbar puncture may be necessary to establish underlying diagnosis once seizures are controlled.
  • NCSE can only be diagnosed by EEG.
  • Investigate to find the underlying cause of seizure

Common Aetiologies of seizures in critical care unit:

Neurological :

Cerebrovascular disease: infarct, haemorrhage, vascular malformation

Vasculitis

Infection: meningitis, encephalitis, brain abscess

Head trauma

Anoxia

Brain tumours

Neurosurgical procedure

Hypertensive encephalopathy/eclampsia/posterior reversible encephalopathy syndrome

Complication of Critical illness:

Acute systemic insult, sepsis, hypotension

Electrolytes imbalances: hyponatremia, hypocalcaemia, hypomagnesaemia, hypophosphatemia (especially in alcoholics), hypoglycaemia

Toxins

Illicit drug use, especially cocaine

Organ failure: renal, hepatic

Medications /substance withdrawal: Benzodiazepine, barbiturates, alcohol

If none of the above causes are identified consider following less common aetiologies:Anti NMDA receptor limbic encephalitis(LE),Anti glutamate receptor LE,Paraneoplastic LE,Hashimotos’ encephalopathy.(5)

c) Treatment

Additional general management

  • Consider intubation to maintain airway patency
  • Monitor for arrhythmias, hypotension and respiratory failure

Antepileptic drug treatment

  • Start phenytoin 20 mg/kg IV load at <= 50 mg/min or Fosphenytoin at 20 mg phenytoin equivalents (PE)/kg at =< 150 mg PE/min
  • Seizure activity not resolving with two anticonvulsants:
  • Give Phenobarbital 10-20 mg/kg IV at <70 mg/min.
  • Call for continuous EEG monitoring
  • Consider neurological consultation
  • Consider administration of following alternative agents:
  • Midazolam drip: 0.2 mg/kg slow IV push, followed by 0.1-2 mg/kg/hr to stop electrographic and clinical seizures or
  • Propofol: 2 mg/kg load and 2-10 mg/kg/hr to stop clinical and electrographic seizures or maintain burst suppression on EEG
  • Valproate 15 mg/kg IV load may be useful as an adjunctive agent.
  • Pentobarbital 3-5 mg/kg IV to induce burst suppression; in most adults pentobarbital bolus 400 mg over 15 min. every 15-30 min. until burst suppression appears is well tolerated, followed by infusion at 0.3-9.0 mg/kg/hr to maintain burst suppression.(7),(8)
  • For all infusions, decrease infusion rate periodically to check EEG burst suppression pattern; if electro cerebral silence occurs, decrease the dose till bursts are seen again.(4)

Guidelines by The Ministry of Health and Family Welfare :

FN Kapadia, Consultant Physician & Intensivist, PD Hinduja National Hospital, Mumbai

Prashant Walse, Associate Intensive Care Unit Consultant, PD Hinduja National Hospital, Mumbai

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supriya kashyap

supriya kashyap

Supriya Kashyap Joined Medical Dialogue as Reporter in 2015 . she covers all the medical specialty news in different medical categories. She also covers the Medical guidelines, Medical Journals, rare medical surgeries as well as all the updates in medical filed. She is a graduate from Delhi University. She can be contacted at supriya.kashyap@medicaldialogues.in Contact no. 011-43720751
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