Approach to Status Epilepticus

Definition
• A seizure (from the Latin sacire, “to take
possession of”) is a paroxysmal event due to
abnormal excessive or synchronous neuronal
activity in the brain.
• Depending on the distribution of discharges,
this abnormal brain activity can have various
manifestations, ranging from dramatic
convulsive activity to experiential phenomena
not readily discernible by an observer.
 Seizure and Epilepsy?
• Epilepsy is a condition in which a person has
recurrent seizures due to a chronic, underlying
process.
• A person with a single seizure, or recurrent
seizures due to correctable or avoidable
circumstances, does not necessarily have
epilepsy.
• Epilepsy refers to a clinical phenomenon rather
than a single disease entity, having a specific
underlying etiology.
Seizure vs Syncope
 Status Epilepticus
• Status epilepticus refers to continuous
seizures or repetitive, discrete seizures with
impaired consciousness in the interictal
period.
• It has numerous subtypes
– generalized convulsive status epilepticus (GCSE)
– nonconvulsive status epilepticus (e.g., persistent
absence seizures or focal seizures with confusion
or partially impaired consciousness, and minimal
motor abnormalities).
• GCSE : Defined as more than 5 minutes of
continuous seizure activity, or more than one
seizure without recovery in between.
• GCSE is a medical emergency

• Can cause irreversible neuronal injury and

cardio-respiratory arrest.
• SE can be overt/convulsive or can be subtle
with occult signs and CNS depression.

• It can also manifest as continuous focal

seizure activity (Epilepsy Partialis Continua)
 Causes
• Acute structural brain injury (eg, stroke, head
trauma, subarachnoid hemorrhage, cerebral
anoxia or hypoxia), infection (encephalitis,
meningitis, abscess), or brain tumor. Stroke is the
most common, especially in older patients.
• Remote or longstanding structural brain injury
(eg, prior head injury or neurosurgery, perinatal
cerebral ischemia, cortical malformations,
arteriovenous malformations, and benign brain
tumors).
• Antiseizure drug nonadherence or
discontinuation in patients with prior epilepsy.
• Withdrawal syndromes associated with the
discontinuation of alcohol, barbiturates, or
benzodiazepines.
• Metabolic abnormalities (eg, hypoglycemia,
hepatic encephalopathy, uremia,
hyponatremia, hyperglycemia, hypocalcemia,
hypomagnesemia) or sepsis.
• Use of, or overdose with, drugs that lower the
seizure threshold (eg, theophylline, imipenem,
high-dose penicillin G, cefepime, quinolone
antibiotics, metronidazole, isoniazid, tricyclic
antidepressants, bupropion, lithium, clozapine
, flumazenil, cyclosporine, lidocaine, bupivacai
ne, metrizamide, dalfampridine, and, to a
lesser extent, phenothiazines, especially at
higher doses).
 Management of SE
• Step 1 – Maintain airway, breathing and
circulation.

• Step 2 –IV line access and take blood sample

for biochemical testing (CBC, Electrolytes, Ca,
Phosphorus, Mg, LFT, RFT, Toxicology and RBS.
Use normal saline, consider thiamine 100mg;
followed by 50 ml of 50% dextrose.
• Step 3 - To terminate the seizure give IV
DIAZEPAM (0.2mg/kg ) or IV LORAZEPAM (0.1
mg/kg ).

• Step 4 – If seizure continues, give

Fosphenytoin 15 to 20mg/kg or Phenytoin 15
to 20mg/kg at 50mg/min infusion in normal
saline. (in children, give a second dose of
lorazepam before giving Phenytoin)
• Step 5 – If seizure continues give second
loading with half of previous dose of
Phenytoin / Fosphenytoin.

• Step 6 – If seizure continues, give

Phenobarbitone 15 mg/kg at 50mg/min.
• Step 7 - – If seizure continues give second
loading with half of previous dose of
Phenobarbitone.

• Step 8 – If seizure continues for more than 40

min give IV anaesthesia
Midazolam 0.2 mg/kg loading dose followed by
1 to 10 microgram/kg/min.
Propofol 1 to 2 mg/kg loading dose.
Thiopentone 5mg/kg.
• If IV access is not available, Diazepam (10 to
20 mg) or lorazepam can be administered
rectally or Fosphenytoin via the IM route.

• IV valproate can be given before anaesthesia

especially in elderly at a dose of 20 to 30
mg/kg at 50mg/min.
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