This document discusses the management of status epilepticus. It defines status epilepticus as continuous seizure activity lasting 5 minutes or more, or recurrent seizures without recovery between seizures. Status epilepticus is a medical emergency that can cause neuronal injury if not treated quickly. The document outlines the clinical presentations, causes, goals of management, and factors associated with poor outcomes of status epilepticus. It also discusses the treatment approach, including airway management, medications, continuous EEG monitoring, and importance of preventing recurrence.

1. MANAGEMENT
OF
STATUS
EPILEPTICUS
Speaker:
Dr. Sharanpreet Kaur

2. References
HARRISON’S principles of internal medicine - 22th Ed
E. Trinka et al.- Report of the ILAE Task Force on Classification
of Status Epilepticus, 2015
Neurocritical care society- Guidelines for the Evaluation and
Management of Status Epilepticus
The 2017 ILAE Classification of Seizures
Status epilepticus: epidemiology and outcomes -
Neurosciences Unit, University College London Medical School

3. SEIZURE
▪A transient
occurrence of signs
and/or symptoms
due to abnormal
excessive or
synchronous
neuronal activity in
the brain.

4. EPILEPSY
▪ At least two unprovoked/reflex (sensory evoked) seizures 24h
apart
OR
▪ One unprovoked seizure and brain demonstrating pathologic
or enduring tendency to have recurrent seizures with
probability of at least 60% of having another seizure in 10 years
OR
▪ An epilepsy syndrome is diagnosed : Cluster of seizure types,
EEG findings and imaging findings occurring together

5. STATUS EPILEPTICUS
▪5 min or more of continuous clinical (convulsive SE) and/or
electrographic (Non convulsive SE) seizure activity
OR
▪Recurrent seizure activity without recovery to baseline
between seizures

6. Medical emergency?
▪Irreversible neuronal injury after 20- 30 min of GCSE
▪Vigorous therapy if seizure > 5 minutes
▪Focal seizures with cognitive dysfunction > 10 min

8. Notes
• Atonic seizures and epileptic spasms would not have
level of awareness specified
• Cognitive seizures
• impaired language
• other cognitive domains
• positive features eg déjà vu, hallucinations,
perceptual distortions
• Emotional seizures: anxiety, fear, joy, etc

12. Clinical Presentation (GCSE)
Generalized tonic-clonic movements of the extremities
Impaired mental status ( coma, lethargy, confusion)
Focal neurological deficits in post ictal period (eg:
Todd’s paralysis)

14. Clinical Presentation ( NCSE)
Seizure activity seen on electroencephalogram (EEG)
without clinical findings of GCSE
 2 Phenotypes :
a) “Wandering confused patient”
b) Acutely ill patient with severely impaired
mental status, with or without subtle
motor movements

15. REFRACTORY SE
Continuation of seizures either clinically or
electrographically after receiving adequate dose of
initial benzodiazepine f/b second acceptable AED

16. New Onset Refractory SE (NORSE)
▪A rare clinical presentation, in a patient without active
epilepsy or other neurological disorder, with new onset
of refractory status epilepticus without a clear acute or
active structural, toxic, or metabolic cause.
▪(MC Cause VIRAL ENCEPHALITIES)

17. SUPER REFRACTORY SE
SE that continues or recurs 24hrs or more after the
onset of anesthetic therapy , including recurrence
of SE on reduction or withdrawal of anaesthesia

18. Causes
▪PRIMARY- Not associated with any identifiable brain lesion
▪SECONDARY-
▪Poor AED compliance
▪Alcohol/ other intoxications/ withdrawals
▪Traumatic
▪Stroke/ tumour
▪Metabolic- hypocalcemia/ hyponatremia/ hypoglycemia/
hyperglycemia
▪Encephalopathy- hepatic/ uremic
▪Sepsis

19. PHYSIOLOGICAL & SYSTEMIC CHANGES :
INITIAL COMPENSATORY PHASE
• Sympathetic activity –
Cardiac output
BP
RBS
Lactate levels
Pupillary dilatation
Increased Cerebral blood flow

20. DECOMPENSATION PHASE
•Cardiorespiratory collapse
•Electrolyte imbalance
•Rhabdomyolysis & delayed Tubular necrosis
•Hyperthermia
• Intracranial pressure & cerebral edema
•Multi organ failure

21. Goals:
Early termination of episode
Prevention of Recurrence
Management of Precipitating cause
Management of complications

24. Status Epilepticus Severity Score (STESS-4)
M.Imp. clinical score to predict in-hospital mortality of patients with SE
STESS  high negative predictive value (NPV) for survival, while it had a low positive predictive value (PPV) for death identifies patients who will survive a SE episode while it fails, in the majority of cases, to identify patients who will die due to a SE episode.
(AO Rosetti et al, 2008)
Features STESS
Consciousness Alert or somnolent/ confused
Stuporous or Comatose
0
1
Worst Seizure Type Simple Partial, complex partial, absence, myoclonic
Generalized convulsive (GCSE)
Nonconvulsive Status epilepticus (NCSE) in coma
0
1
2
Age <65 years
>65 years
0
2
History of previous
seizure
Yes
No or Unknown
0
1
Total 0-6

25. Best practices during seizures
▪Ineffective breathing pattern- maintain proper airway
▪Risk for injury
▪Protect the patient’s head
▪Place the patient in left lateral position
▪Loosen constrictive clothing
▪Do not restrain
▪Ease to the floor if patient is seated
▪Do not place anything in mouth/ hand
▪Record the time the seizure began and ended

27. Management of SE
▪Airway
▪Breathing
▪Circulation
▪Secure 02 large bore iv lines
▪Blood samples for RBS, RFT, Electrolytes, toxicology,
and AED levels
▪Iv fluid NS, Dextrose, Thiamine
▪EEG, CT Brain if required- later

30. Factors associated with poor outcome in SE
▪Duration of seizures
▪Underlying etiology
▪De novo development in hospitalized patients
▪Older age
▪Focal neurological signs at onset
Better Prognosis-
• Symptomatic SE
• Young patient
• Low AED levels

31. Continuous EEG Monitoring
▪Started within 1 hour of onset of SE if there is suspicion of
ongoing seizure activity.
▪Duration- at least 48 hours
▪Need for Continuous EEG
▪15- 20 % may become NCSE
▪Difficult to differentiate post ictal vs NCSE
▪Electromechanical dissociation in subtle GCS
▪To titrate dose of IV anaesthetics
▪Decide when to taper AEDs

32. Important Points
▪After emergency control of SE- maintenance therapy should
be started to prevent recurrence of seizures
▪Known Epilepsy cases- usual AED can be continued depending
on serum AED levels.
▪In patients presenting for the first time as SE, drugs like
Phenytoin or Sodium Valproate used to control the status can
be continued as maintenance therapy.

33. What can the patient do?
▪Epilepsy health alert to be carried at all times
▪Drug compliance
▪Avoid alcohol and other drugs
▪Avoid driving/ high risk jobs
▪Apprise others of their condition

34. What can we do?