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STATUS EPILEPTICUS
WITH RECENT GUIDELINES
1. Cardiorespiratory collapse
2. Electrolyte imbalance
3. Rhabdomyolysis & delayed tubular necrosis
4. Hyperthermia
5. Multi organ Failure
6. Raised ICP & cerebral oedema
• Nonconvulsive status epilepticus
• Diverse - severe impairment of consciousness to
subtle phenomena.
• Motor manifestations if any –needs careful CNS
exam.
4. Management of complications
Approach: Diagnostic workup
All patients
• Obtain IV access
• Monitor vital signs (ABC).
• Head CT (appropriate for most cases)
• Labs: blood glucose, CBC, renal function tests, Calcium,
Magnesium, electrolytes, AED levels.
• cEEG monitoring (preferably)
Consider based on clinical presentation
• Brain MRI
• Lumbar puncture
• Toxicology panel (i.e. isoniazid, TCAs, theophylline, cocaine,
sympathomimetics, organophosphates, cyclosporine)
• Other relevant investigations as per the need
– Lorazepam
0.1- 0.15 mg/kg i.v, upto 4-6 mg over 1-2 minutes
If SE persists, repeat every 5-10 minutes
• Diazepam
One of the drug of choice for first line management of SE
• Good results, easy to administer. (fast acting, short lasting)
• More lipid soluble, hence short distribution half-life.
• Anti-seizure effect 15-30min.
• Sufficient cerebral levels are achieved within 1 min of IV
administration and about 20 mins after rectal
administration.
• Elimination half life abt 24 hrs (may accumulate)
• Side effects -- hypotension, bradycardia,
respiratory depression, cardiac arrest,
tolerance, depresses mental status.
• In children and elderly :
Rectal Diazepam 0.5 mg / kg in children and 10 mg
in elderly are also good alternatives.
• Lorazepam
• Has emerged as preferred BZD for treatment of SE
• The veteran affairs (VA) co-operative study demonstrated
advantage of IV Lorazepam over Phenytoin.
• Less lipid distribution with distribution half life of 2-3
hours
• So Fast acting, longer lasting compared to Diazepam
– Longer therapeutic half-life. Anti-seizure effect for
6-12hrs.
– 2mg dose, upto a max dose of 8mg in total
• Main disadvantage is rapid devlopment of tolerance,
hence repeated doses are less effective and has no role
in long term therapy.
• - If Benzodiazepines are successful in stopping
• GCSE, the decision to add another agent
• depends on the underlying etiology.
• Cheap • Expensive
Fosphenytoin Vs. Phenytoin
• SO Fosphenytoin injection has the following advantages over
phenytoin
100% bioavailability
better tolerated at site of injection.
can be given IV more rapidly .
can be given IM when cardiac monitoring is not necessary
• But has the following disadvantages
– conversion of fosphenytoin to phenytoin takes about 15
minutes. Hence inappropriate for the initial treatment of
status epilepticus (SE).
– transient paraesthesia and pruritus occur more frequently
than with phenytoin.
– the use of phenytoin equivalents may be confusing.
PHENOBARBITAL
• Used in SE when BZD and Phenytoin have
failed.
• Loading dose – 15-20 mg/kg
• Causes sedation and hypotension, so airway
protection should be done.
• Diluted in Polyethylene Glycol which results in
complications like renal failure, myocardial
depresion and seizures.
SODIUM VALPROATE
• FDA approved use in SE in 1997
• Resective surgery
• Vagal nerve stimulation
• Hypothermia- decrease brain metabolism
which is neuroprotective.
• Electroconvulsive therapy - ECT-dose-1 session
daily for 3-8 days. Mechanism-not known
STATUS EPILEPTICUS
NO YES
If seizure persists after 24 hrs, try emerging novel therapies: Ketamine bolus 0.5-4.5
mg/kg infusion (upto 5 mg/kg/hr ) ; Immunomodulation IV Methylprednisolone or
IVIg; Resective surgery ; Ketogenic diet ; hypothermia
THANK YOU
References.
Results:
• 34 prescriptions for intravenous levetiracetam in patients with
status epilepticus were noted.
• All patients had at least one co-morbidity condition
• The seizure control rate was 61.8%
• 41.2% survived
Intravenous and hadhas
levetiracetam angood
improved status
efficacy at discharge.
and may be a good option
for status epilepticus.
Levetiracetam Lorazepam
In first instant, 76.3 75.6 Lorazepam
SE controlled • Significantly higher need
of artificial ventilation
In those resistant, 70.0 88.9
• Insignificantly higher
SE controlled
frequency of hypotension
24-h freedom 79.3 67.7
from seizure