This document provides guidelines for the management of status epilepticus. It defines status epilepticus as 5 minutes or more of continuous seizure activity or recurrent seizures without recovery between seizures. Status epilepticus can be classified based on age of onset, etiology, clinical features, and EEG features. Common causes include stroke, low anti-epileptic drug levels, alcohol withdrawal, anoxic brain injury, and metabolic disturbances. Initial management involves stabilization, benzodiazepine administration, and consultation with neurology if seizures continue. For refractory or subtle cases, continuous EEG monitoring, additional anti-epileptic drugs, and anesthetic drugs like midazolam or propofol may be used. Nonpharmacological

1. Dr.W.A.P.S.R.WEERARATHNA
Registrar in Medicine
Ward 10/02

2. Objectives…
Current definition of status epilepticus
Classification
Epidemology
Etiology
Clinical manefestations-convulsive/nonconvulsive
Diagnosis
Types of status epilepticus
Current guidelines for the management of status
epilepticus-Neurocritical care society guide lines-2013
Refferences

3. Definition-2012 Neurocritical care
society Guidelines
5 minutes or more of
1.continuous clinical and/or electrographic seizure
activity or
2. recurrent seizure activity without
recovery(returning to baseline) between seizures

4. classsification
Based on
1.Age of onset
2.Etiology
3.Clinical features
4.EEG features

5. Ictal EEG activity
Motor Activity Conciousness Genaralized Focal/Lareralized
Intense
(convulsive)
Markedly to
severely impaired
Tonic-
clonic,tonic,clonic,
myoclonic
hemiconvulsive
Normal to mildly
impaired
Myoclonic(primari
ly gen.epi.)
Epilepsia partialis
continua
Absent or subtle
(nonconvulsive)
Markedly to
severely impaired
Absence(
including
typical,atypical,
late onset
Subtle or purely
electrographic
Complex partial
Subtle or purely
electrographic
Normal to mildly
impaired
Absence
(including
typical,atypical,
late onset)
Simple
partial(including
aura continua)or
mild or
int.complex partial

6. Status epilepticus-Epidemiolody
US-20-40/100 000
Bimodal-< 1 year & >60 years
Nonconvulsive status epilepticus-
10% - an altered level of conciousness
16% - confused elderly patients

7. Status epilepticus –common
etiology
1.stroke,including haemorrhagic - 20%
2.low AED levels - 35%
3.alcohol withdrawal - 15%
4.anoxic brain injury - 15%
5.Metabolic disturbances - 15%
6.remote brain injury/congenital malformations -20%
7.infections - 5%
8.brain neoplasms - 5%
9.Idiopathic - 5%

8. Clinical features
Genaralized convulsive status epileptics-
Self-perpetuating genaralized tonic-clonic seizure or
of a series of genaralized tonic-clonic seisures without
return to consciousness in between seizures.
Initial compensatory phase-sympathatic overdrive
increased C.O
increased BP
increased BS
increased blood lactate levels

9. Decompensation –homeostatic faliure
Redused C.O/ BS/lactate/O2 levels leading to
1. Cardiorespiratory collapse
2. Electrolyte imbalance
3. Rhabdomyolysis & delayed tubular necrosis
4. Hyperthermia
5. MOF
6. Raised ICP & cerebral oedaema

10. Nonconvulsive status epilepticus
Diverse-severe impairment of consciousness to subtle
phenomena.
Motor manifestations if any –needs careful CNS exam.
Prolonged subjective sensory phenomena(ie. aura
continua), negative S/S, changes in cognition or
behavior-simple partial status epilepticus.
Often mistaken for psychogenic/psychiatric disorders.

11. Diagnosis
Diagnosis of nonconvulsive status epilepticus in
critically ill patients.
Correlate with poorer outcome
EEG patterns are difficult to interpret(equivocal
patterns)-criteria is not validated.
A trial of rapidly acting IV AED is used to observe
improvement in both clinical  EEG by several hours.
Other available modalities
Cont….

12. Brain imaging.( perfusion/metabolic imaging)
Intracranial monitoring with intra cortical EEG.
Brain tissue O2 monitoring.
Cerebral micro dialysis.

13. Other forms or status epilepticus
Refractory status epilepticus
Status epilepticus that fails to respond to 2 AED.
Nearly 40% of status epilepticus are refractory!
Predictors- encephalitis/nonstructural
causes(HIE)/delayed diagnosis & treatment/subtle
status epilepticus.

14. Malignant/super- refractory status epilepticus
Status epilepticus that does not respond to a course of
anesthetic drug.
20% of refractory status epilepticus patients.
Needs combination therapy (AED & Anesthetic drugs)
/immune therapy.

15. Management of status epilepticus-
convulsive/nonconvulsive
Initial management- (first 5 min)
Stabilize A/B/C etc…
Peripheral IV access
Continuous Monitoring & support-SpO2/BP/PR etc…
Labs-ABG/AED levels/BS/Metabolic profile-
(Ca/Mg/Po4) FBC/LFT/RFT-BUN & S.Cr,
cTnI,toxicology screening etc…
Give Dextrose-D50W 50 ml-unknown glucose
Thiamine 100 mg IV prior to dextrose

16. Benzodiazepines are the treatment of choice
followed by IV AED’s!! (SR-HQ)-strong recc./high
qua)
Lorazepam 4 mg IV push over 2 min(evidence I-A)
If still seizing-after 5 min rpt once –consult neurology
If NO IV access-Diazepam 20 mg using IV solution
RECTALLY (evidence IIa-A) or
Midazolam 10 mg IN/IM/buccal IV solution(evidence
I-A) -consult Neurology
If sseizures continue-rapid sequence(RSI) ETT(you
may use succinylcholine/avoid etomidate!

17. Within 30 min..
Midazolam load-0.2 mg/Kg IV push-rpt 0.2-
0.4mg/Kg untill seizure stops ( max.2.0 mg)
IVI-initial 0.1mg/Kg/hr: maintenance 0.05-
2.9mg/Kg/hr)-(evidence-IIb-B)
Simultaneous fosphenytoin/phenytoin(evidence IIa-
B)/valproate(evidence IIa-A)/phenobarbital(evidence
Iib-C)/levetiracetam(evidence Iib-C)

18. Fosphenytoin: 20mg PE/Kg IV, may give as slower
rate(50-150mg/min)
If still seizing-additional 5mg/Kg PRN
Valproate:40mg/Kg IV, may give @ a slower rate(over
10-30 min)
If still seizing-additional 20 mg/Kg PRN
Alternative IVI: Propofol-load 1-2 mg/Kg IV push, rpt
every 3-5 mins untill seizure stops.(max10 mg/kg)

19. >30 min…
Give at least 1 continuous IVI with boluses of either
phenobarbital/propofol/midazolam
Phenobarbital: load 5mg/Kg IV at 50 mg/min ,rpt untill
seizure stops, IVI-1mg/Kg/hr
Perform neuroimaging when convulsive activity is
controlled.
Begin continous EEG,if pt.doesn’t awaken rapidly or if
continuous IV Rx is used.
Treat hypothermia.
Consider LP & or AB if clinical suspicion of infection.

20. Management of refractory status
epilepticus & subtle status
epilepticus
In the ICU that can provide cEEG(evidence SR-VLQ)
Additional treatment-(switch to or start a new AED)
preferred over rebolouses of AED used initially.
(evidence SR-LQ)
Continuous IV midazolam ,propofol,phenobarbital +/-
intermittent bolouses or
Intermittent IV AED in nonintubated
patients(evidence SR-VLQ)

21. Use maintenance AEDs for the transition from
continuous IV.(evidence SR-VLQ WR –VLQ)
Titrate to seizure suppression or burst suppression
(evidence WR-VLQ)
Electrographic control for 24-48 hrs before weaning.

22. Nonpharmacologic approaches
used in status epilepticus.
ECT-dose-1 session daily for 3-8 days.
Duration-up to 2/52.
Mechanism-not known
AED doses reduced before ECT.
A/E- due to short anesthesia
Hypothermia-decrease brain metabolism which is
neuroprotective.
Acid-base, electrlyte imbalance ,thrombosis, infection
arrythmias may occur.
Resective surgery.
Ketogenic diet.

23. Refferences.
Review article-Status Epilepticus-Lawrence J
.Hirsch,MD,FAAN: Nicolas Gaspard,MD,Phd-2013