defination and treatment

1. BY
DR.MALIHA
PGR(PEADS IV)

2. 
Status Epilepticus :
 The International League Against Epilepsy
(ILAE) and the World Health Organization
currently define SE as a “condition
characterized by an epileptic seizure that is
so frequently repeated or so prolonged as to
create a fixed and lasting condition.
DEFINATION

3. 
Status Epilepticus is defined as 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.
PRACTICAL
DEFINATION

4. 
Generalized convulsive SE
 a series of generalized tonic- clonic seizures
without return to consciousness in between
seizures.
1. Initial compensatory phase -sympathetic
overdrive
 a. increased C.O.
b. increased BP
 c. increased BS
 d. increased blood lactate
level
Clinical features

5. 
2.Decompensation Phase –homeostatic failure
 a. Cardiorespiratory collapse
 b. Electrolyte imbalance.
 c. Rhabdomyolysis & delayed tubular necrosis.
 d. Hyperthermia
 e. Multi organ Failure
 f. Raised ICP & cerebral edema
GCSE……

6. 
Non convulsive SE (NCSE);
refers to ongoing EEG seizure activity without
associated clinical signs.
Refractory Status Epilepticus :
If seizure failed to respond to therapy, usually
with at least 2 (such as a benzodiazepine and
another) medications.
 New-onset refractory status epilepticus
(NORSE): refer to refractory status epilepticus in
a patient without prior epilepsy.
CLINICAL FORM OF
SE

7. Fever-induced refractory epileptic
encephalopathy(FIRES);
a syndrome of refractory status epilepticus that
is associated with acute febrile infections,
appears to be Para infectious in nature, and to be
highly drug resistant but responsive to the
ketogenic diet.
Continue………..

8. 
ILAE Definitions of Status
Epilepticus
Time after which if
seizures do not
terminate patient is
considered in status
epilepticus (t1)
Time after which
ongoing seizures
have long term
consequences (t2)
Convulsive status
epilepticus
5min 30min
Focal status
epilepticus with
impaired
consciousness
Absence status
epilepticus
10min
10–15 min
60min
Unknown

9. 

10. 
 incidence of status epilepticus ranges between
10 to 60 per 100,000 population.
 Status epilepticus is most common in children
younger than 5 yrs. of age, with an incidence in
this age group of >100 per 100,000 children.
Approximately 30% of patients presenting
with status epilepticus are having their first
seizure, and approximately 40% of these later
develop epilepsy.
EPIDEMOLOGY

11.  Fever 36%
 Medication change 20%
 Unknown 9%
 Metabolic 8%
 Congenital 7%
 Anoxic 5%
Other (trauma, vascular, 15%
infection, tumor, drugs)
CAUSES

12. 
 Antibiotics;
Penicillin ,Isoniazid , Metronidazole
Anesthetics, Narcotics;
Halothane, Enflurane , Fentanyl ,Cocaine ,
 Psychopharmaceuticals ;
Antihistamines , Antidepressants , Phencyclidine ,
Tricyclic antidepressants ,Antipsychotics.
Drugs which can cause
seizures

13. 
Failure of desensitization of AMPA
glutamate receptor , thus persistence of
increase excitability.
Reduction of GABA mediated inhibition as a
result of intracellular internalization of
GABAA receptor .
PATHOPHYSIOLOGY

14. 
 Out of hospital management
– Community education
– Patients must be brought to the hospital at
the earliest
Hospital emergency management
 ICU management – It is helpful to have a
protocol in every hospital.
STEPS OF S.E
MENANGEMENT

15. 
Stages of menangent of SE are:
1.Premonitoing stage; prolonged seizure at
home/before hospitalization (5min)
2. First stage; at hospital (5-20 min)
3.Second stage; established status epilapticus
(from 10-30 min)
4.Third stage; refractory status epilapticus
(>40-60 min)
STEPS OF
MENANGEMENT

16. 
 1. Look for medical identification.
 2. Protect the person from nearby hazards.
 3. Loosen ties or shirt collars.
 4. Protect the head from injury.
 5. Turn the person on his side to keep the airway
clear.
 6. Time record.
 7. Reassure when consciousness returns.
 8. Ask whether hospital evaluation is wanted, call an
ambulance
FIRST AID
RECOMMANDATION

17. 
ACUTE SEZIURE
MENANGEMENT

18. 
A Oxygen, oral airway. Avoid hypoxia.
B Consider bag-valve mask ventilation.
consider intubation
C IV/IO access. Treat hypotension,
NOT hypertension
0-5 minutes ; Stabilize the
patient

19. 
Consider hypoglycemia, thiamine deficiency
, intoxication.
Give glucose (2-4 ml/kg D25%, infants 5
ml/kg D10%), unless normal OR
hyperglycemic
 Thiamin 100 mg IV first.
Naloxone may be given immediately if
suspected.
(0-5 minutes)…

20. 
After initial screening history and Physical
examination;
Labs;
 – Na , K, Ca , Mg, PO4 , BUN, Creatinine, glucose
 – CBC
 – Liver function tests, ammonia
 – Anticonvulsant level
 – Toxicology
 – Blood C/S
Initial investigations
(0-5 minutes)….

21. 
 EEG
 CT scan/MRI scan –Indicated for focal seizures
or history of trauma or bleeding disorder.
 Lumbar puncture –Always defer LP in
unstable patient, but never delay
antibiotic/antiviral Rx if indicated.
Work-Up (when stable)

22. 
Benzodiazepines;
 – Lorazepam 0.05- 0.1 mg/kg IV (rectal dose
same) up to 2 mg over 1-2 minutes OR
–Diazepam 0.2- 0.5 mg/kg IV up to 6-10mg over 1-
2 minutes –Diazepam 0.5 mg/kg rectally.
 –Midazolam 0.15-0.3 mg/kg IV ; nasal or Buccal
(0.5 mg/kg) is used if no IV line –
 If seizure persists, repeat every 5-10 min.
5-15 min- Rapid acting
Anticonvulsant

23. 
1.Fosphenytoin
15-20mg/kg IV/IM at 3mg PE/kg/min(max 150mg)
2.Phenytoin ;
15-20 mg/kg IV at the rate not exceed 1mg/kg/min.
3.Phenobarbital
 –15-20 mg/kg (neonate 20-30 mg/kg) IV over 15-20
min.
 Onset 15-30 min
 –May cause hypotension, respiratory depression.
15-35 min; Long acting-
Anticonvulsants

24. 
Initial choice of long acting
anticonvulsants in SE

25. 
 Levetiracetam 20-30mg/kg IV OR Valproate
20mg/kg IV
 Phenobarbital if Phenytoin used.
 Additional phenytoin or FP 5 mg/kg ( 10 mg/kg )
max up to 30 mg ,
 Additional phenobarbital 5 mg/kg/dose every 15–
30 min (max total dose of 30 mg/kg)
 be prepared to support respirations.
If SE -persists
(45 minutes)

26. 
 Consider Diazepam infusion, pentobarbital
(Barbiturate coma), midazolam, paraldehyde or
general anesthesia infusion in PICU
 Midazolam 0.2 mg/kg bolus & 20-400 mcg/kg/hr.
infusion.
 Propofol 1-2 mg/kg then 2-10 mg/kg/hr. infusion
 Avoid paralytics.
Seizures Persists
(60 minutes)

27. 
 Induction of Barbiturate coma for 48 hrs
 IV loading thiopental 2–4 mg/kg till a
burst suppression EEG pattern till 48 hrs
 check phenobarbital level to be normal.
Paraldehyde :loading 150–200 mg/kg IV for
15–20 min, then 20 mg/kg/hr in a 5%
concentration in a glass bottle freshly
prepared
Still Seizures Persists…

28. 
 General anesthesia: if barbiturate coma is not
option.
 Halothane and Isoflurane;
Acts by reversing cerebral anoxia and metabolic
abnormalities, allowing the previously administered
anticonvulsants to exert their effect.
Still Seizures Persists….

29. 
 Lidocaine - some positive trials .
 Gabapentin / Vigabatrin / Lamotrigine
 Felbamate - blocks NMDA receptors
 Ketamine
 Potential therapy under study is induction of
acidosis(e.g. by hypercapnia), which could reduce
neuronal excitability.
Possible new drugs for
Status

30. 
 NCSE is a term used to denote a range of conditions
in which electrographic seizure activity is prolonged
and results in non convulsive clinical symptoms.
 Up to 20 % of children with SE have non -
convulsive SE after tonic - clonic SE.
 If child does not begin to respond to painful
stimuli within 20 - 30 minutes after tonic - clonic
SE, suspect non - convulsive SE .
 Do Urgent EEG.
 Treatment include parenteral AEDs.
Non - convulsive SE ?

31. 
COMPLICATIONS

32. 
Depend on
Age, etiology, and duration correlate directly
with mortality.
The highest mortality is seen in the elderly;
fortunately, children have a far low mortality
rate then do adults.
Mortality rates of SE in children varies
between 3 and 9 percent.
Prognosis

33. 
 Better outcome if seizure stopped earlier, so no need
to wait.
 Always ABC first.
 Lorazepam - best 1st line Rx
 Fosphenytoin - surpasses Phenytoin for SE, and can
be given IM in difficult situation.
 Propofol - advantages over barbiturates for resistant
SE, low toxicity , quick action, and fast recovery
upon discontinuation.
Take-Home points -

34. 