STATUS EPILEPTICUSSTATUS EPILEPTICUS

Department of NeurologyDepartment of Neurology

Yashoda Hospital,Yashoda Hospital,

Secunderabad.Secunderabad.

STATUS EPILEPTICUSSTATUS EPILEPTICUSDefinitionDefinition

• Continuous seizures or repetitive, discrete Continuous seizures or repetitive, discrete

seizures with impaired consciousness in the seizures with impaired consciousness in the

inter-ictal period. Duration of seizure activity inter-ictal period. Duration of seizure activity

should be 15-30 min. ORshould be 15-30 min. OR

• Single seizure lasting for >10min. ORSingle seizure lasting for >10min. OR

• More than 3 seizures within 30 min.More than 3 seizures within 30 min.

Etiology Etiology

• Drug change/noncomplianceDrug change/noncompliance• StrokeStroke• CNS infectionCNS infection• AlcoholAlcohol• HypoxiaHypoxia

Continued…Continued…

• MetabolicMetabolic• Intra-cranial space occupying Intra-cranial space occupying

lesionlesion• TraumaTrauma• Fever/infectionFever/infection• CongenitalCongenital

Classification Classification

• Convulsive statusConvulsive status

• Primary generalizedPrimary generalized

• Secondary generalizedSecondary generalized

• Non convulsive statusNon convulsive status

• Epilepsia Partialis Continua Epilepsia Partialis Continua

• Myoclonic Status EpilepticusMyoclonic Status Epilepticus

CONVULSIVE STATUS CONVULSIVE STATUS

EPILEPTICUSEPILEPTICUS • Generalised tonic clonic convulsionGeneralised tonic clonic convulsion• Consequences Consequences

-Early: - Because of release of -Early: - Because of release of

CatechloaminesCatechloamines

-Late: - Failure of Cerebral and -Late: - Failure of Cerebral and systemicsystemic

protective measures protective measures

Early ConsequencesEarly Consequences

• Heart rate & Blood pressureHeart rate & Blood pressure• Blood GlucoseBlood Glucose• Cardiac Arrhythmias Cardiac Arrhythmias • Gradual rise in Temperature Gradual rise in Temperature

(Prolonged Hyperthermia) (Prolonged Hyperthermia) • Acidosis ( Lactic acid production)Acidosis ( Lactic acid production)

Late ConsequencesLate Consequences• Fall in BPFall in BP• Loss of cerebral auto-regulation Loss of cerebral auto-regulation • Hypoglycemia due to exhaustion of Hypoglycemia due to exhaustion of

glycogen stores & Neurogenic glycogen stores & Neurogenic insulin secretion insulin secretion

• Cerebral Oedema Cerebral Oedema • Rhabdomyolysis leading to ATN, Rhabdomyolysis leading to ATN,

Hyperkalemia and hyponatraemiaHyperkalemia and hyponatraemia• Rarely DIC Rarely DIC

Management Management

First stage (0-10min)First stage (0-10min)• Oxygen and Cardio respiratory Oxygen and Cardio respiratory

Resuscitation Resuscitation

-Cardio respiratory assessment -Cardio respiratory assessment

- Secure airway- Secure airway

-Resuscitate if require -Resuscitate if require

-Oxygen should always be -Oxygen should always be administered administered

Second Stage(1-60min)Second Stage(1-60min)

• Monitoring Monitoring --Regular Neurological ObservationRegular Neurological Observation -Pulse, BP, ECG-Pulse, BP, ECG• IV lines IV lines -Normal saline -Normal saline -separate lines for different drugs. -separate lines for different drugs. -Drugs should not be mixed-Drugs should not be mixed• Emergency Anti-convulsant TherapyEmergency Anti-convulsant Therapy

Continued…Continued…

• Emergency Investigations- Emergency Investigations- -Sugar,ABG Renal and liver Function Test-Sugar,ABG Renal and liver Function Test

-Calcium, Magnesium Level, CBP -Calcium, Magnesium Level, CBP

-Anticonvulsant level-Anticonvulsant level

• IV glucose & thiamineIV glucose & thiamine -50ml of 50% dextrose should be given I.V. if -50ml of 50% dextrose should be given I.V. if

hypoglycemia is suspected.hypoglycemia is suspected.

-If there is h/o alcoholism 250mg of Thiamine -If there is h/o alcoholism 250mg of Thiamine should be given I.V. should be given I.V.

Third Stage(0-60/90min)Third Stage(0-60/90min)

• Establish etiology: -Establish etiology: - -Age, History -Age, History

-Investigations-Investigations

-CT/MRI Brain, CSF examination-CT/MRI Brain, CSF examination• Medical complications -Medical complications -Hypoxia, Hypo- & Hypoxia, Hypo- &

Hyper-tension, Cardiac arrhythmias, Cardiac Hyper-tension, Cardiac arrhythmias, Cardiac failure, lactic acidosis, Hyperpyrexia, failure, lactic acidosis, Hyperpyrexia, Hypoglycemia , Electrolyte disturbance, Hypoglycemia , Electrolyte disturbance, raised ICP, organ failure, Rhabdomyolysis, raised ICP, organ failure, Rhabdomyolysis, DICDIC

Fourth StageFourth Stage

• ICU monitoringICU monitoring -ECG, Pulseoxymetry -ECG, Pulseoxymetry

• Seizure and EEG monitoringSeizure and EEG monitoring -Prolonged Status Epilepticus -Prolonged Status Epilepticus

-Comatose Ventilated Patients -Comatose Ventilated Patients

• Initiate long term anticonvulsant Initiate long term anticonvulsant therapytherapy

-Start long Term AEP-Start long Term AEP

Anti-convulsant drug Anti-convulsant drug TherapyTherapy

• Stage of Early StatusStage of Early Status -Lorazepam: -4 mg IV Bolus (0.07mg/kg)-Lorazepam: -4 mg IV Bolus (0.07mg/kg) Can be repeat after 10 min.Can be repeat after 10 min.

-Midazolam: -0.1 – 0.3 mg/kg IV bolus –at 4 mg/min -Midazolam: -0.1 – 0.3 mg/kg IV bolus –at 4 mg/min

• Adverse effectsAdverse effects: : • respiratory depressionrespiratory depression• HypotensionHypotension

Continued…Continued…

• Seizures continuing / Stage of Seizures continuing / Stage of Established SeizureEstablished Seizure

• PhenytoinPhenytoin:-:- 15-20mg/kg Bolus dose IV at the 15-20mg/kg Bolus dose IV at the

rate of 50mg/minrate of 50mg/min..• FosphenytoinFosphenytoin:-:- 15-20mg PE/kg Bolus dose IV 15-20mg PE/kg Bolus dose IV

at the rate of 150mg/minat the rate of 150mg/min

(Repeat dose of 5-10mg/kg can be given)(Repeat dose of 5-10mg/kg can be given)• PhenobarbitalPhenobarbital:-10mg/kg Bolus IV at the rate of:-10mg/kg Bolus IV at the rate of

100mg/min.100mg/min.

• Seizures continuing / Stage of Seizures continuing / Stage of Refractory StatusRefractory Status

• --general anesthesia should be inducedgeneral anesthesia should be induced• PropofolPropofol:-:- 2mg/kg IV bolus,Repeat if necessary, 2mg/kg IV bolus,Repeat if necessary,

followed by infusion (5mg/kg/hr)followed by infusion (5mg/kg/hr)• ThiopentalThiopental:-:- 100-250mg IV bolus over 20 sec. with 100-250mg IV bolus over 20 sec. with

further 50mg bolus every 2-3 min.until seizure further 50mg bolus every 2-3 min.until seizure control followed by IV infusion(3-5mg/kg/hr)control followed by IV infusion(3-5mg/kg/hr)

• MidazolamMidazolam:- 0.1-0.3mg/kg IV bolus dose at the rate :- 0.1-0.3mg/kg IV bolus dose at the rate of 4mg/min followed by infusion(0.05-0.4mg/kg/hr)of 4mg/min followed by infusion(0.05-0.4mg/kg/hr)

If seizures have been controlled for 12hrs., If seizures have been controlled for 12hrs., reduce the dose over further 12hrs.reduce the dose over further 12hrs.

If seizure recurs again GA agent should be givenIf seizure recurs again GA agent should be given

Non-Convulsive Status Non-Convulsive Status EpilepticusEpilepticus

• Continuous Neuronal Discharge but no Continuous Neuronal Discharge but no ConvulsionsConvulsions

• Diagnosis dependant on EEGDiagnosis dependant on EEG• Presentation:-known epilepsy patient Presentation:-known epilepsy patient

-Prolonged change in personality -Prolonged change in personality

-Prolonged Post ictal stage ( >30min)-Prolonged Post ictal stage ( >30min)

-Recent onset of Psychosis-Recent onset of Psychosis

Treatment Treatment Type Type TreatmentTreatment

Typical absence status Typical absence status epilepticus epilepticus

IV or oral IV or oral benzodiazepinesbenzodiazepines

Complex partial status Complex partial status epilepticus epilepticus

Oral clobazamOral clobazam

Atypical absence status Atypical absence status epilepticus epilepticus

Oral valproate Oral valproate

Non-convulsive status Non-convulsive status epilepticus in comaepilepticus in coma

IV PhenytoinIV Phenytoin

(fosphenytoin)or (fosphenytoin)or phenobarbitalphenobarbital

Epilepsia Partialis Epilepsia Partialis ContinuaContinua

• Regular or irregular clonic muscular Regular or irregular clonic muscular twitching, affecting limited part of body, twitching, affecting limited part of body, occuring for minimum of 1hr, at interval occuring for minimum of 1hr, at interval of not more than 10sof not more than 10s

• CausesCauses:- Stroke, Trauma, cerebral :- Stroke, Trauma, cerebral inf./abscess, hyperglycemia, inf./abscess, hyperglycemia, hyponatraemia hyponatraemia

• EEGEEG:-Focal abnormality / may be Normal:-Focal abnormality / may be Normal• TreatmentTreatment:- Treat underlying :- Treat underlying

cause.Antiepileptic drug can be cause.Antiepileptic drug can be considered to prevent complex partial or considered to prevent complex partial or secondary generalize seizures. secondary generalize seizures.

Myoclonic Status Epilepticus Myoclonic Status Epilepticus in comain coma

• Well recognized complication of Well recognized complication of cardiorespiratory arrest (Hypoxia)cardiorespiratory arrest (Hypoxia)

• Characterized by spontaneous and Characterized by spontaneous and stimulus sensitive myoclonusstimulus sensitive myoclonus occurs occurs within 24hrs of coma.within 24hrs of coma.

• Treatment:-Clonazepam, valproate, Treatment:-Clonazepam, valproate, piracetam piracetam

• Prognosis:- Usually PoorPrognosis:- Usually Poor

STATUS EPILEPTICUSSTATUS EPILEPTICUS-action plan-action plan

Drugs-Drugs-

1.1. Initiate with Initiate with lorazepam lorazepam or or midazolammidazolam

2.2. MaintainMaintain with phenytoin / with phenytoin / fosphenytoinfosphenytoin

3.3. If status persists- If status persists- phenobarbitalphenobarbital

4.4. If status persists- If status persists- pentobarbital or pentobarbital or propofol,thiopental anaesthesia with propofol,thiopental anaesthesia with ventilatory supportventilatory support

Other drugs in Status Other drugs in Status epilepticusepilepticus

ValproateValproate• IV bolus 15-30 mg/kgIV bolus 15-30 mg/kg

MagsulfMagsulf

• Indication – Refractory statusIndication – Refractory status

• Dose:-4 gm IV bolus followed by 5 gm deep IM on Dose:-4 gm IV bolus followed by 5 gm deep IM on both sides. rpt. 4hrlyboth sides. rpt. 4hrly

ClonazapeamClonazapeam

• Indication – Early status (Alternative to lorazepam)Indication – Early status (Alternative to lorazepam)

• Dose Dose 1-2 mg bolus over 30 sec.1-2 mg bolus over 30 sec.