STATUS EPILEPTICUS IN ADULTS
COPE
KJ Oommen, M.D., Director
Definition
1. Major motor (convulsive) status is 3 seizures uninterrupted by
consciousness or a single prolonged seizure greater than 1/2 hour.
2. Spike wave stupor (Absence or Petit mal status) [1,2] and complex partial
(psychomotor) status [3,4,44] are prolonged alterations of consciousness
verified by EEG as epileptic.
3. Epilepsia partialis continua is focal motor status [5] (rarely sensory).
4. Generalized status myoclonicus - stupor or coma with myoclonus (diffuse
and focal) [26,50.51].
5. Subtle status - stupor, roving eyes, myoclonic twitches, needs EEG [45].
Incidence [6,7,8]
1. At the Lynchburg Training School with 3000 patients, 892 had epilepsy.
Status occurred in these patients at 5% per year.
2. In a group of 241 patients with ETOH withdrawal seizures, 100 had a single
seizure, 133 had 2-4 seizures, 8 developed status (3%).
3. Of the 100,000 head trauma cases/year, 5% develop seizures, unknown
percent develop status.
Natural History [9]
1. Overall mortality 15-20%, but a downward trend to 10% more recently.
2. Spontaneous remission possible but no double blind studies can be done.
3. If status persists for 4 hours despite treatment, mortality up to 50%.
If it persists greater than 12 hours, then mortality 80%.
Pediatric [10,11,24]
1. Pediatric status is entirely different from adult.
2. Pediatric status is rare, especially considering that epilepsy is mainly
a disease of infancy and childhood.
3. Status occurs with the child's first seizure most commonly.
4. Drug withdrawal is a very rare cause.
5. Infectious and congenital causes most common.
6. Responds well to treatment except for catastrophic causes.
7. Mortality 5-10%.
8. Treatment [25,28,29,30,52,55].
CAUSES
1. Outpatient -- patient presents to hospital already in status.
a. Anticonvulsant withdrawal [27]
b. Alcohol withdrawal
c. Hysterical [47,57]
d. Tumor
e. Other
i. Vascular--stroke, hemorrhage, aneurysm, subdural
ii. Infectious -- bacterial, viral
iii. Metabolic -- uremia, hepatic, electrolytes
iv. Toxic -- poisons, drugs, non-CNS infection
v. Head trauma
vi. Idiopathic -- possibly 1/3 of all causes
(1) previous status
(2) cryptogenic
vii. Immune -- lupus, multiple sclerosis
viii. Degenerative -- Alzheimer's
2. Inpatient -- patient hospitalized for other reasons
a. Patient has history of epilepsy
i. Iatrogenic -- change in anticonvulsant levels
(1) For purpose of specific therapy
(2) Forgot to order meds
(3) Antagonized by other drugs
ii. Secondary to diagnostic test -- contract procedures (CT,
myelogram, IVP, arteriography)
iii. Same as outpatient
b. Patient has no history of epilepsy
i. Neurosurgical procedure
ii. Metabolic
iii. Same as outpatient
MANAGEMENT ERRORS
1. Single Seizure
2. Hysterical Seizure
3, Inadequate Treatment
Immediate treatment
1. Start IV, draw bloods (including anticonvulsant levels), push 50 cc D50W.
(All patients in status are in coma and hypoglycemia may be the cause.
Don't forget the thiamine.)
2. Examine patient.
3. Monitor vital signs.
4. Intubate all patients.
5. Protect patient from external injury, never leave patient alone.
Theory
Status epilepticus is a medical emergency. A treatable cause of death in
status is hypoxia in most cases. Full support of the patient eliminates this
possibility. The seizures themselves are not an imminent cause of mortality
or morbidity but, seizures kill brain cells [34].
Definite Treatment [12,13,14,55]
1. Non-specific
a. Blood pressure
b. Respirations
c. Correct electrolytes
d. pH -- acidosis lowers seizure threshold, treat with bicarb if pH<7.1
e. Lower fever
f. Antibiotics/LP if indicated
g. If neurologic exam dictates, treatment of underlying cause may
proceed concurrently with drug therapy, e.g., neurosurgical
decompression.
h. Resist the urge to get a STAT CT Scan. It will not alter your
immediate plans and may delay treatment.
2. Specific -- all drugs IV, all levels should be "toxic."
The laboratory ranges do not apply to status!
NOTE: There is no evidence to date which clearly marks any drug or
drug combination as the best choice.[15] However, the use of
a fast acting drug to quickly stop the status, and a long
lasting drug to prevent recurrence is the correct practice.
a. Valium [16] -- fast acting, short lasting
i. Good results, easy to administer.
ii. 10 mg push over 30 seconds, may be repeated. If two doses fail
to stop status, then further doses probably won't work either.
iii. Side effects -- hypotension, bradycardia, respiratory
depression,cardiac arrest, depresses mental status.
b. Lorazepam [31,32] -- fast acting, medium lasting.
i. Similar to Valium in most ways.
ii. 4 mg push may be repeated.
NOTE: Respiratory depression is a major problem only in the
extubated patient.
c. Clonazepam [17] -- fast acting, long acting.
i. Generally not used because of lack of experience.
ii. Others get good results in both major motor and absence status.
iii. 1 mg push, may repeat.
iv. Supposedly less side effects than Valium.
v. Patients get refractory to drug over long periods of time.
d. Phenytoin [18] -- fast and long acting.
i. Presently used concomitantly with a benzodiazepine as the long
lasting drug, half-life 20 hours.
ii. Must be given as close to the vein as possible since it
precipitates out in the line [19,20]. It's pH is 12,
all i.v. fluids are pH 4-6.
iii. 17 mg/kg at 50 mg/min under EKG monitor.
iv. Has been very effective as primary drug. Wilder, et al. used
dose of 10-17 mg/kg at infusion rates less than 93 mg/min
without cardiac or respiratory complications and controlled 90%
of his status patients in 30 minutes.
v. Side effects -- cardiac arrhythmia, hypotension and respiratory
depression synergistic with other anticonvulsants (due to
vehicle: propylene glycol--antifreeze).
vi. Advantages -- does not depress consciousness.
vii. Get level >20 ug/ml and maintain levels in this range.
e. Phenobarbital [9,33] -- long lasting.
i. Frequently added to Valium and phenytoin when status has not
lightened in the first 1/2 hour.
ii. Half life 3 days.
iii. 400 mg/10 mins, may repeat to side effects (usually 20 mg/kg).
iv. Side effects -- powerful depressant of all functions.
v. Get levels >40ug/ml and maintain levels in this range.
f. Paraldehyde [21,22] -- intermediate
i. An older drug which has fallen out of favor by most, but can be
very effective.
ii. 4% solution from fresh paraldehyde at 100ml/hr for 1 hr.
May go to 8% if necessary.
iii. Side effects -- respiratory and cardiovascular depression,
metabolic acidosis.
iv. Has been pulled from the market, but can be made sterile via
millipore filter.
Refractory Patient
1. Diagnosis -- is the patient still in status clinically or
electrographically? Don't treat periodic lateralized epileptiform
discharges (PLEDs) on the EEG if this is the only EEG finding. [53]
2. Decide whether to stop active treatment and observe, or get aggressive.
3. Effective blood levels of all drugs are usually at or above the "toxic"
range.
4. Further treatment requires EEG monitor.
a. Valium drip, titrate rate clinically.
b. General anesthesia to straight line EEG.
1. Sodium Thiopental [23,39,40,41,42].
2. Inhalational gases - Isoflurane [38], halothane, nitrous oxide [46]
5. Practices of dubious value
a. Lidocaine [35].
b. Rectal valproate [36,37].
c. Magnesium sulfate [43,54].
d. Tegretol, Depakote per N.G. [49].
e. Rectal benzodiazepines [48].
f. Rectal nembutal.
g. Rectal chloral hydrate [56].
6. Status can last days, weeks and even months. [58]
CONVULSIVE STATUS EPILEPTICUS PROTOCOL
FOR THE EMERGENCY ROOM
Draw Bloods including anticonvulsants
Start IV
Push D50
Intubate ALL patients
The cause of death is hypoxia in most cases, either from the status or
respiratory depression from anticonvulsants.
Protect patient from external injury - NEVER leave the patient alone.
Push 10 mg Valium IV over 30 seconds or Lorazepam 4 mg.
May repeat once in five minutes if still seizing.
Load IV with 17 mg/kg (1 gm minimum) phenytoin at 50 mg/min. monitoring v.s.
and EKG. Phenytoin is administered either directly into the vein or close to
the hub, NEVER dripped, IM or p.o.
ALL meds IV.
Go to phenobarbital, if still seizing after phenytoin has been given.
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