STATUS EPILEPTICUS

 To recognize status epilepticus as medical

emergency
 To understand and be able to identify the
causes of status epilepticus
 To have a structural approach to the
diagnosis and management of status
epilepticus
 Seizure : clinical manifestation of abnormal
neurologic function caused by abberant electrical
firing of neuron in the brain.
 3 categories : generalized, partial, complex
partial.
 Status epilepticus : a continuous or intermittent
seizure activity for more than 5 minutes
without regaining consciousness
 Several form status epilepticus :
- Continous generalized seizure activity
- Recurrent generalized seizures whereby between
episodes the patient has persistent depressed level
of consciousness
- Recurrent partial seizure
- Non convulsive seizures --> difficult to identify only
 depressed level of consciousness : only the symptom
 confirmed by Electroensephalography
 Continous seizure patient to Emergency room
what is a diagnose???

Aggresive treatment : important !!!

High mortality and morbiditidy
Must terminated within 30 minute

Avoid permanent neurological sequelae.

 Withdrawal Toxin
- Anticonvulsant - Lidocain,
Acute Structural Injury
- Tumor
- Alcohol - anticholinergic,
- intracranial hemorrhage
- Benzodiazepine, - salycylates,
- Barbiturat - lithium, isonianid
Metabolic
Chronic abnormalities
Pregnancy/prepartum
structural - Hypoglicemia
- prior Injury - hypo/hypernatremia
Traumatic brain - hypocalcemia
injury/intracranial Cerebral Injury - uremia
surgery - Infection - hypomagnesemia
- Cerebral palsy - Trauma
- AVM - Hypoxia
Chronic epilepsy
 Status epilepticus confined to early childhood
- Neonatal status epilepticus
- Status epilepticus in specific neonatal epilepsy
syndrome
- Infantil spasms
 Status epilepticus confined to later childhood
- Febrile status epilepticus
- Status in childhood partial epilepsy syndrome
- Status epilepticus in myoclonic – static epilepsy
- Electrical status epilepticus during slow wave sleep
- Landau – Kleffer syndrome
 Status epilepticus occurring in childhood and adult life
- Tonic – clonic status epilepticus
- Absence status epilepticus
- Epilepsia partialis continua
- Status epilepticus in coma
- Specific form of status epilepticus in mental retardation
- Syndrome of myoclonic status epilepticus
- Simple partial status epilepticus
- Complex partial status epilepticus

 Clinical practice status epilepticus classified :

- Convulsive status epilepticus
- Non convulsive status epilepticus
 History  aloanamnesis (family, EMS personel)
 Important to know :
- time of onset seizure
- history of prior seizure
- ingestion of toxin
- associated symptom : fever, headache
- past medical history (pregnancy, abuse, cancer,
HIV, tuberculosis)
 Find clue of seizure : abrupt onset, foaming at the
mouth, tongue biting, urine or fecal incontinence, post
ictal state
 True medical emergency
 Should always begin with the ABC
- Airways management
- Breathing
- Circulation assessment
 Brief neurological examination
 Investigation and treatment should take place
simultaneously in patient with SE
 Bedsite glucose level
 CBC, electrolyte, anticonvulsant drug level, venous
blood gas, calcium, Mg, ETOH level, serum salicylates,
urine toxicology screen
 ECG, LP, CT Scan, other imaging
 EEG monitoring
 Initial treatment with ABC
airway management, oxygen, iv line, cardiac
monitoring, IV fluid
 Check for hypoglycemia  1 amp D50W
 Benzodiapine  loading dose of phenytoin 
intubated (if not already) and phenobarbital
administration iv or intraosseous
 Benzodiazepine
1. Lorazepam : 2-4mg IV q2min, up to 0,1mg/kg
maximum 8-10mg
2. Diazepam :5-10 mg IV, up to 0.15 mg/kg IV,
maximum 20-30 mg
3. Midazolam : 10 mg IM (patient >40 Kg)- if IV
route unavailable

IV Lorazepam >> diazepam

IM midazolam = IVLorazepam in prehospital
Benzodiazepin  5-10 minute if fails

- Lorazepam 2-4mg IV,max start second IV Line and add

8-10 mg
- Phenytoin 20mg/Kg IV ICU consultation
- Diazepam 5-10mg IV up with rate of 25-50 mg/min
to 0.15mg/kb max 20-30 (may repeat 10 mg/Kg - Phenobarbital 20mg/kg
mg doses once to total dose IV at 50 mg/min
-Midazolam 10 mg IM 30mg/Kg
-midazolam 0.2 mg/kg IV
- Fosphenytoin : 20 PE/kg loading dose and then
IV or IM at rate 100-150 mg infusion 0.05-0.5 mg/kg/hr
PE/min
- Propofol 2-5mg/kg IV
loading dose and then 2-
10mg/kg/hr
 CNS depression
 Cardiovascular stress : MI, arrhythmias, cardiac
arrest
 Hypotension
 Respiratory failure
 Repeated muscle contraction : rhabdomyolysis
 Increased parasympathetic activity : sweating,
salivary and bronchial hypersecretion
 Non-cardiogenic pulmonary edema
 Mortality for 1st episode up to 20-30%
 Prolonged SE (> 30 minute)  permanent
neuronal damage
 Acute symptomatic SE >> 6x risk of death than
chronic.
 Patient with generalized convulsive status
epilepticus (GCSE) respon better to treatment
 prognosis >> than Non Convulsive SE
(NCSE).
 Difficult to differentiated from SE, can occur
concomitantly in patient with history seizure
 Suspect patient not responding to usual treatment
 Patient pseudoseizure  not elevated transient
physiologic leukocytosis, elevated serum lactate and
prolactine
 Pseudoseizure  tend occur in response to emotional
upset, tend to protect themselves from injury during
the event.
 Head thrashing, pelvic thrusting, non symmetric, clonic
extremity movement  typical of pseudoseizure
 SE is defined as more than 5 minutes of continuous seizure
activity or series of seizures between which the patient
doesnot regain complete consciousness
 Withdrawal of anticonvulsant, cerebrovascular ds and
alcohol withdrawal account for majority of cases of SE
 After securing ABC, check capillary glucose level, administer
IV benzodiazepine to terminate seizure, followed by loading
dose of IV phenytoin, if failed should be intubated (if not
already) and IV phenobarbital, midazolam, or propofol
administered
 If no IV acces is immediately available the best initial
medication choice is midazolam IM followed by interosseous
line insertion
 Suspected pseudoseizure or NCSE in patient not responding
to usual treatment.
Thank you