Definition and management of status epilepticus

1. STATUS EPILEPTICUS

2. WHAT IS STATUS EPILEPTICUS?
• Life-threatening neurologic disorder that is essentially an acute
prolonged epileptic crisis- failure of seizure termination.
• Sufficiently prolonged (or repeated at sufficiently brief intervals) to
produce an enduring epileptic condition, either in terms of
convulsions or mental state (i.e they do not recover to their original
state of awareness).
• Current definition is “>30 mins of continuous seizure activity or two
or more sequential seizures without full recovery of consciousness
between seizures” however time has been formally/informally
shortened to seizural activity lasting >5 mins in some areas.

3. Etiology
1. An exacerbation of a pre-existing seizure disorder
2. Initial manifestation of a seizure disorder
3. An insult other than a seizure disorder
Seizures can either be generalized convulsive, simple partial, or non-
convulsive.
The most severe form of status epilepticus often associated with severe
brain damage is generalized tonic-clonic status

4. Etiology
• In patients with a pre-existing seizure disorder ask about adherence
to medication or any recent changes to medications as that can
precipitate SE.
• Metabolic
-hypoglycemia, hyperbilirubinemia
-electrolyte imbalances e.g. hypo/hypercalcemia, hypomagnesemia,
hypo/hypernatremia
-inborn errors of metabolism (rare cause)

5. • CNS causes
-meningitis, encephalitis, abscess
-acute trauma (hypoxic injury- especially in <1 week olds, intracranial
bleeds esp where there’s hx of head trauma)
-prev trauma which may lead to scar formation
-tumor
-AV malformations
-venous thrombosis

6. • Fever
-hx of episodes of convulsions when febrile
-age 6 months to 5 years
• Toxins
-drug overdose or toxin ingestion e.g. lead poisoning

7. Approach to patient with SE
• MEDICAL EMERGENCY!
• Manage the airway and breathing
• Ensure iv access
• Check glucometer- if hypoglycemic give 10% dextrose
• Stop convulsion

8. Neonates
• Phenobarbitone is first line.
• Give loading dose of 20mg/kg iv, if convulsions persist after 30 mins
give further doses of 10mg/kg to a max dose of 40mg/kg in total.
• Always have a bag mask available in case of respiratory depression.
• Maintain at a dose of 5mg/kg nocte which is started 12 hours after
loading dose. Put patients on maintenance after 2 loading doses.

9. • If phenobarb is not available use phenytoin.
• Loading dose of 20mg/kg as an infusion over 1 hour, if seizure persists give
another loading dose at 10mg/kg. Slow infusion to prevent purple glove
syndrome- a rare complication of intravenous phenytoin use that typically
present with pain, edema and discoloration at the injection site that
spreads to the distal limb. Poorly understood but thought to be due to
extravasation of phenytoin into tissues causing delayed soft tissue injury.
• Maintenance is 3-5 mg/kg/d in 2 to 3 divided doses
NB: diazepam is avoided in neonates because of its very prolonged sedative
effect and short duration of anti-epileptic effect.

10. Children older than a month
• Diazepam 1st line
• May be given iv or per rectum
• Children up to 5 years- give 0.3mg/kg iv stat over 2 to 5 mins. Do not
exceed 5mg per dose.
• >5 years- 1mg slow iv every 2 to 5 minutes up to max dose of 10mg.
• Or give 0.5mg/kg rectally if iv access difficult.
• Don’t exceed 2 doses within 24 hour period

11. Refractory status epilepticus
• Inform senior
• Drugs that can be used if seizure persists as per senior’s discretion:
- Midazolam infusion
- Ketamine
- Propofol

12. • Airway must be kept clear with gentle naso/oropharyngeal suctioning
if secretions are present.
• Nurse in recovery position- left lateral position
• If pyrexial undress the child and control external environment to
reduce fever- use of antipyretics during the fit wont stop the fit.
• Avoid feeds, Keep NPO if severely ill or lethargic.
• insert NGT if you are to use oral meds.
• Give O2 if patient is in respiratory distress
• Monitor blood glucose, temperature, blood pressure or O2 sats as
indicated

13. Take hx to determine precipitant
• Is it the first episode? Are they on any anti-seizure meds?
• Fever? Hx of febrile convulsions?
• Poor feeding? Reduced playfulness? Irritability? Inconsolable crying?
Lethargy?- CNS signs are non specific in younger child.
• In an older child- headache? Vomiting? Rigid posture? Confusion?
Photophobia?
• Hx of travel?
• Head trauma?
• Toxin/drug ingestion?

14. • Hx of diarrhea/vomiting
• Hx of facial or LL swelling
• Fam hx of epilepsy
In neonates its important to ask about:
-any hx of birth asphyxia
-any hx of jaundice
-Intrauterine infection

15. Examination
• Glucometer stat
• Malaria RDT
• Temperature checks
• Look for signs that might point to possible etiology as guided by hx
-neck stiffness, af fontanelle, pupil size & reflexes, posture, AVPU, LOC
-signs of dehydration
-jaundice, severe pallor
-blood pressure, peripheral or facial edema
-primitive reflexes in neonates
-SPO2

16. HYPOGLYCEMIA
• Give 10% dextrose at 5ml/kg iv (2-4ml/kg in neonates), if iv access can
not be established quickly, give per nasogastric tube.
• Usually 10% dextrose is not available in our setting and has to be
prepared using 50% dextrose and normal saline.
• If iv glucose is not available, give one teaspoon of moistened sugar
sublingually and repeat every 20 mins to prevent relapse. Monitor for
early swallowing which leads to delayed absorption.
• Repeat glucometer after 30 mins, if its still low give bolus again

17. • If glucometer cannot be performed and child is unconscious, treat as
hypoglycemia and if LOC improves then presume hypoglycemia.