08/03/2021
Status epilepticus
- Criteria: ≥ 5 min of continuous seizures OR ≥ 2 seizures with consciousness not being fully regained in the interictal period
**Seizure**
A seizure is irregular electrical activity in the brain caused by the hyperexcitability of neurons, especially in cortical areas. Hyperexcitability, in turn, is the result of altered cellular electrochemical properties, which may be caused, for example, by electrolyte imbalances. The etiology varies according to age. Seizures may be provoked by acute conditions (e.g., stroke, traumatic brain injury, alcohol withdrawal) or unprovoked, in which case they are indicative of epilepsy.
**Etiology**
Common causes are withdrawal from antiepileptic drugs; , metabolic disturbances; (e.g., hyponatremia), drug toxicity; (e.g., tricyclic antidepressants), structural brain lesions/injury (e.g., tumors, trauma, stroke), and CNS infections.
**Treatment of status epilepticus**
1- Initial assessment and supportive treatment:
- Place patient in recovery position to prevent injury.
- Quick neurological examination (to determine type and cause of status epilepticus) and general medical evaluation (particularly airway, breathing, and circulation)
- Establish secure IV access (two, if possible), collection of blood for routine blood tests (particularly electrolytes and glucose levels), toxicology screen, antiepileptic drug levels, and arterial blood gas (ABG) analysis
- Supportive therapy as necessary (e.g., oxygen, glucose, thiamine naloxone )
- Monitoring of vital signs: especially oxygen saturation (via pulse oximetry), blood pressure, cardiac action, and breathing
- If patient does not regain consciousness after seizures stop or nonconvulsive status epilepticus is suspected → continuous EEG monitoring
- If acute brain injury (e.g., intracerebral hemorrhage) is suspected → obtain a cranial CT scan
- If CNS infection is suspected → conduct a lumbar puncture
2- Pharmacological interruption of seizures: initial treatment
A- First line: IV lorazepam; second line: IV diazepam or midazolam → if IV access is not possible or drugs are administered by someone who is not a medical professional → select another application form (e.g., re**al diazepam, buccal or intranasal lorazepam/midazolam)
— If the patient does not respond within 1 minute → administer additional lorazepam (or a second-line benzodiazepine)
If the patient does not respond within another 10–20 minutes → saturation with fosphenytoin via separate access (alternatively: phenobarbital, levetiracetam, or valproate)
— If seizure activity does not stop despite application of a benzodiazepine and a nonbenzodiazepine antiseizure drug → refractory status epilepticus
B- No later than 45–60 min after onset: continuous administration of anesthetics with intubation and ICU monitoring; e.g., thiopental, propofol, or midazolam
3- Nonbenzodiazepine therapy (to prevent recurrence): fosphenytoin or valproate
**Prognosis**
Mortality of ∼ 20% (in adults with first occurrence of GCSE)
