Outline your principles of management of status epilepticus.
Diagnosis: status epilepticus as > 5 minutes generalised convulsive, non-convulsive, (no return of consciousness), simple partial [Definition 2 or more convulsions with no recovery in between, or continuous convulsion > 30 min (alternative more recently accepted definition is > 5 min)]
Support: Airway, Breathing, Circulation.
Control: using hierarchy of drugs: benzodiazepine (midazolam) + phenytoin loading, propofol, barbiturate (phenobarbitone loading, thiopentone infusion), isoflurane, others. EEG to confirm, avoid paralysis.
Restore: therapeutic prophylaxis drugs if appropriate - check levels. Consider add newer generation agent in difficult cases.
Look for and treat cause:
History of epilepsy, Anti-convulsant compliance, Check and correct biochemical disturbance eg Na
(appropriate speed), hypoglycaemia, low Ca++, severe azotemia.
Look for toxins (TCA, theophylline, amphetamine and other recreational drugs, salicylate, glycols, alcohols, hydrocarbons etc).
Diagnose infective, hypoxic, vascular, metabolic or structural (trauma, neoplasm), physical(hyperthermia) cause - CT, LP, MR, porphyrins.
Treat CNS viral and bacterial infection empirically until excluded. Eclampsia specific management including LSCS, Mg, BP control.
Don't forget factitious epilepsy - look for atypical features, check lactate, EEG, reflexes etc. Consider drug withdrawal.
Treat complications - aspiration, rhabdomyolysis, hyperthermia.
Its another one of those.
- Attention to the ABCS, with management of life-threatening problems simultanous with a rapid focused examination and a brief history.
- An attempt to reverse the status epilepticus with a bolus dose of benzodiazepine may be undertaken while the above assessment takes place.
- The need for airway support shoud be assessed
- The patient will likely need to be intubated
- This has the added benefit of exposing the patient to barbiturate anaesthetics, benzodiazepines or propofol
- Routine pursuit of normoxia and normocapnea;
- Minute volume may need to be titrated up in view of increased metabolic CO2production
- Circulatory support
- Hypotension arsiing from the use of sedating medications may require vasopressors
- Supportive management
- Nutrition, thromboprophylaxis and pressure area care need attention, as the patient may remain immobile for a prolonged period
- Specific investigations
- A CT brain and an EEG to confirm status epilepticus (if it is non-convulsive)are all but mandatory
- Drug screening of serology, urine and history should be undertaken, to exclude reversible causes (eg. intoxication or withdrawal)
- Specific management
- Correction of the aetiology (eg. intoxication)
- First line antiepileptics should be given (phenytoin )
- If response is not achieved, second and third line agents may be deployed (levitiracetam, valproate, benzodiazepine infusion)
- Barbiturate coma may be required with EEG monitoring of response
Related content would consist of the following chapters:
Chapter 49 (pp. 549) Disorders of consciousness by Balasubramanian Venkatesh
Chapter 50 (pp. 560) Status epilepticus by Helen I Opdam
Brophy, Gretchen M., et al. "Guidelines for the evaluation and management of status epilepticus." Neurocritical care 17.1 (2012): 3-23.