Status epilepticus why medical emergency

In adults, the common causes include: Stroke Imbalance of substances in the blood, such as low blood sugar Drinking too much alcohol or having alcohol withdrawal after previous heavy alcohol use Who is at risk for status epilepticus?

There are many risk factors for status epilepticus including: Poorly controlled epilepsy Low blood sugar Stroke Kidney failure Liver failure Encephalitis swelling or inflammation of the brain HIV Alcohol or drug abuse Genetic diseases such as Fragile X syndrome and Angelman syndrome Head injuries What are the symptoms of status epilepticus?

These are possible symptoms of status epilepticus: Muscle spasms Falling Confusion Unusual noises Loss of bowel or bladder control Clenched teeth Irregular breathing Unusual behavior Difficulty speaking A "daydreaming" look How is status epilepticus diagnosed?

How is status epilepticus treated? Healthcare providers may use anti-seizure drugs to treat the problem, including: Diazepam Lorazepam Phenytoin Fosphenytoin Phenobarbital Valproate These drugs are given through an IV or an injection into a muscle.

What are the complications of status epilepticus? Can status epilepticus be prevented? Key points about status epilepticus Status epilepticus has many causes. Some can be prevented such as low blood glucose or alcohol and drug abuse. Individuals who have epilepsy must take their medicine as directed. A seizure that lasts more than 5 minutes, or having more than 1 within a 5 minute period is an emergency that requires immediate medical care.

Next steps Tips to help you get the most from a visit to your healthcare provider: Know the reason for your visit and what you want to happen.

Before your visit, write down questions you want answered. Bring someone with you to help you ask questions and remember what your provider tells you. At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you. Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.

The elimination half-life is 72 h. Contraindications include severe liver dysfunction. The main side effects are respiratory depression patients will often require intubation and ventilation , prolonged sedation, allergy including Stevens-Johnson syndrome , and blood dyscrasias.

Propofol is an alkylphenol 2,6-diisopropylphenol that has been used extensively for the induction and maintenance of anesthesia and for sedation in the intensive care unit.

Propofol is a global CNS depressant. It directly activates the GABA receptor. The excellent pharmacokinetics and favorable adverse effect profile makes propofol the ideal drug to treat RSE. The two main advantages of propofol are a rapid onset and short duration of action. Propofol is a highly lipophilic agent with a large volume of distribution.

This property results in its rapid uptake and elimination from the CNS, thereby giving it rapid onset of action and allowing rapid recovery upon discontinuation. Recovery is rapid even after prolonged use. Propofol is metabolized by glucuronidation and sulfate conjugation, and does not accumulate even after long-term infusion. No dose reduction is required in patients with hepatic or renal disease Concomitant IV benzodiazepines allows use of a lower and safer dose of propofol, i.

Benzodiazepines, when administered concomitantly with IV propofol, have a dose-sparing effect on propofol and so lower doses can be equally effective. SE stops within 10 min in most situations. The propofol infusion syndrome is a potentially fatal condition characterized by severe metabolic acidosis, hyperlipidemia, rhabdomyolysis, and cardiovascular collapse.

The full-blown syndrome tends to occur only in those individuals with a genetic susceptibility. However, the risk appears to be higher in children. Other contraindications include allergy to soybean oil, egg lecithin, or glycerol. It should be used with caution in combination with carbonic anhydrase inhibitors such as zonisamide and topiramate due to the risk of refractory acidosis.

Hyperlipidemia and creatine kinase levels can be useful early markers of this syndrome. Midazolam is a fast-acting, water-soluble benzodiazepine with a half-life of 4—6 h. Midazolam is an alternative to propofol. The drug undergoes hepatic transformation into an active metabolite that is cleared by the kidneys. Midazolam is typically started after securing endotracheal intubation and ventilator assistance.

It is usually started with a loading dose of 0. The maintenance dose is 0. The antiepileptic effect of midazolam lasts from minutes to hours. One of the major disadvantages of midazolam is tachyphylaxis, because of which the dose often has to be increased several fold to maintain seizure control. Furthermore, with prolonged infusion, midazolam accumulates in the body, which may result in a prolonged time to awakening.

High-dose barbiturate therapy is a treatment option in RSE. This regimen is often associated with hemodynamic instability and immune paresis. Due to these side effects, high-dose barbiturate therapy is reserved for those patients who do not respond to midazolam or propofol infusion.

Intravenous pentobarbitone and thiopentone are two regimens that are often tried. Pentobarbitone has lower lipid solubility than thiopentone. Hence it takes a longer time to achieve its peak effect and it shows better correlation between serum concentrations and clinical effect, especially after prolonged infusion. The usual maintenance dose is 0. High-dose phenobarbitone therapy can be considered in patients with RSE who get breakthrough seizures when midazolam or propofol is being tapered off after achieving short-term electrocerebral suppression.

Phenobarbital has no anticonvulsant ceiling effect. The sedative and respiratory-depressant properties of phenobarbital are subject to tolerance over a relatively short time period, but the anticonvulsant activity is not. The aryl moiety of the drug confers potent anticonvulsant properties at doses below values that depress the brainstem reticular formation and consciousness. This relatively high therapeutic index allows nonanesthetic doses of the drug to be effective.

The high phenobarbital doses administered to treat SE can thus be gradually withdrawn until consciousness returns. Initiation of high-dose phenobarbital therapy is the key to safe withdrawal of pentobarbital. Inhalational anesthetics offer an alternative approach to the treatment of RSE. The advantages include efficacy, rapid onset of action, and the ability to titrate the doses according to the effects demonstrated on the EEG.

Isoflurane and desflurane are the two agents that have been tried in the treatment of RSE because of the safety associated with their long-term administration. Isoflurane is the agent of choice for RSE. Isoflurane undergoes significantly less metabolism in the liver than halothane. Regardless of seizure type, isoflurane and desflurane have consistently stopped epileptic discharges with adequate, sustained electrographic burst suppression within minutes of initiation of therapy.

Prolonged use of inhalational anesthetics is well tolerated. In selected cases of RSE that have failed to respond to medical management, surgical intervention can be considered as a last resort. This is particularly applicable to cases with an underlying surgically remediable lesion.

It is important to ensure that adequate maintenance therapy is instituted simultaneously with the emergent treatment to prevent relapse of SE. Patients already receiving AEDs will require some dose escalation or adjustment according to the prevailing blood drug levels.

If additional medication is needed, the most appropriate AEDs are topiramate and levetiracetam as these drugs can be started at high doses with a low risk of idiosyncratic reactions. A patient who develops SE in the course of ethanol withdrawal may not need AED therapy once the withdrawal has run its course.

On the other hand, patients with a new, ongoing, epileptogenic insult e. Certain medical conditions can present with SE. The management of SE in such situations may need special approaches.

Porphyria can occasionally be complicated with SE. Most of the enzyme-inducing AEDs such as phenobarbitone, phenytoin, carbamazepine, and lamotrigine are contraindicated in porphyria as they increase the porphyrin production. SE in these cases can be treated with parenteral magnesium sulphate or IV lorazepam without aggravating porphyria.

Levetiracetam is a new AED that can be tried in this situation. High carbohydrate and hematin intake tends to reduce porphyrin production and thereby ameliorate the situation. When SE is due to intoxication with isoniazid, administration of high doses of pyridoxine can be useful.

Seizures associated with overdoses of tricyclic antidepressants and antimuscarinic agents may respond to physostigmine. Pyridoxine will be especially useful for suspected pyridoxine-dependent seizures.

Aggressive treatment with anticonvulsants and plasma exchange are useful for thrombotic thrombocytopenic purpura complicated by SE. For eclamptic seizures, parenteral magnesium sulphate could be used initially. Benzodiazepine can also be given without causing a depressant effect on the fetus. Comprehensive management of SE includes treatment of precipitants and causes such as noncompliance with AED therapy, acute infections, high fever, hypoglycemia, electrolyte imbalance, organ dysfunction, drug intoxication, poisoning, alcohol withdrawal, excess use of alcohol, stroke, trauma, and hypertensive encephalopathy.

These causes must be actively pursued and treated. Patients with SE are prone to several medical complications. Prolonged seizures can lead to multiple organ dysfunctions. Medications such as pentobarbitone may depress the immune response of the subjects and thereby predispose them to infections. Non-neurological complications include nosocomial and ventilator-associated pneumonia, atelectasis, adult respiratory distress syndrome, neurogenic pulmonary edema, pulmonary embolism, hypovolemia, myocardial dysfunction, hypertension, arrhythmias, stress ulcer, gastrointestinal bleed, constipation, diarrhea, paralytic ileus, renal dysfunction, urinary tract infection, and vascular catheter—related sepsis.

It is important to watch for these complications so as to detect them as early as possible and institute prompt treatment.

SE often fails to respond or gets protracted because of deficiencies in the management. Common errors include misdiagnosis, wrong route of administration intramuscular phenytoin , inadequate dosing of AEDs, delay in switching to a second-line drug, delay or failure in initiating maintenance therapy with appropriate drugs, failure to detect and treat the precipitating or underlying causes and complications of SE, and delay in providing cardiorespiratory support with endotracheal intubation and vasopressor administration.

SE has a variable prognosis. The factors associated with high mortality include refractory seizures, acute symptomatic etiologies e. Cardiovascular decompensation during SE, medical complications, and overtreatment with AEDs may also predispose to excess mortality. Coma with recurrent electrographic status and multiorgan dysfunction carries poor clinical outcome. SE is a medical emergency that need to be evaluated and managed in a systematic manner.

Patients who have persistent generalized seizures beyond 5 min deserve to be treatedt as SE. It is important to initiate treatment as soon as the patient is observed, preferably in the prehospital phase itself in order to prevent resistance to medications. Those patients who have failed to respond to two of the first-line drugs lorazepam and fosphenytoin in most instances need to be managed as RSE.

Such patients should be moved to intensive care services, where they could be administered second-line drugs barbiturates or benzodiazepines , with ventilator support and continuous EEG monitoring. If there is no facility for intubation, they can be treated with nonsedating medications such as intravenous valproate, levetiracetum, or oral topiramate. It is equally important to attend to the general medical condition of the patient, even as the AEDs are being administered.

Source of Support: Nil. Conflict of Interest: Nil. National Center for Biotechnology Information , U. Ann Indian Acad Neurol. Ajith Cherian and Sanjeev V. Thomas 1. Sanjeev V. Author information Article notes Copyright and License information Disclaimer. For correspondence: Dr. E-mail: moc. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC. Abstract Status epilepticus SE is a medical emergency associated with significant morbidity and mortality. Keywords: Anticonvulsants, barbiturates, lorazepam, midazolam, phenytoin, propofol, refractory status epilepticus, status epilepticus. Introduction Status epilepticus SE is a common medical emergency associated with high morbidity, if not mortality. Definitions Status epilepticus A landmark meeting in Marseilles in was the first scientific meeting to be devoted to the topic of SE, and the published proceedings is the first monograph on SE.

Classification of status epilepticus Semiologically and electrophysiologically there are several types of seizures; these have been broadly classified as either generalized or partial seizures by the International League Against Epilepsy. Nonconvulsive status epilepticus Nonconvulsive SE NCSE refers to continuous or near-continuous generalized electrical seizure activity lasting for at least 30 min, but without physical convulsions.

Epidemiology It has been estimated that up to , cases of SE occur annually in the US, with 55, associated deaths. Causes Children Adults Infection Open in a separate window. Table 2 Commonly used drugs that may predispose to status epilepticus by lowering the seizure threshold or by increasing the clearance of antiepileptic drugs.

Pathophysiology Clinical and experimental studies have shown that SE evolves through an initiation phase to a maintenance phase. Table 3 Systemic and cerebral pathophysiological changes associated with convulsive status epilepticus.

Diagnosis Occasionally, the diagnosis of SE can be difficult. Table 4 Mimics of generalized convulsive status epilepticus. Treatment SE is one situation where emergent symptomatic relief control of seizures takes precedence over systematic evaluation. Algorithm 1. General measures As with any critically ill patient, the first step in the management of a patient with SE would be to ensure an adequate airway and to provide respiratory support. Table 5 Blood investigations in a patient with status epilepticus.

Random blood sugar Electrolytes - sodium, potassium, calcium, magnesium Complete blood count Renal function test, liver function test Antiepileptic drug level Arterial blood gas. Pharmacotherapy Since only a small fraction of seizures go on to become SE, the probability that a given seizure will proceed to SE is small at the start of the seizure but increases as the seizure duration increases.

Table 6 Pharmacokinetic parameters of commonly used drugs for status epilepticus[ 34 ]. Prehospital treatment of SE The longer an episode of SE continues, the more refractory to treatment it becomes and the greater is the likelihood of complications.

In-hospital treatment of SE The drug of choice for in-hospital treatment of SE is intravenous lorazepam. Intravenous valproate Sodium valproate is a broad spectrum AED that has been in clinical use for several decades.

Oral topiramate Topiramate is another new AED with a mechanism of action that is different from that of the benzodiazepines and other first-line AEDs. Management with ventilator assistance Patients with RSE who have not responded to the first-line treatment will require admission to the intensive care unit for more aggressive management under assisted ventilation. Phenobarbital Phenobarbitone is a long-acting barbiturate that acts by potentiation of GABA and by interfering with sodium and potassium transport across the cell membrane.

Propofol Propofol is an alkylphenol 2,6-diisopropylphenol that has been used extensively for the induction and maintenance of anesthesia and for sedation in the intensive care unit.

Midazolam Midazolam is a fast-acting, water-soluble benzodiazepine with a half-life of 4—6 h. Role of inhalational anesthetics Inhalational anesthetics offer an alternative approach to the treatment of RSE. Neurosurgical treatment of refractory status epilepticus In selected cases of RSE that have failed to respond to medical management, surgical intervention can be considered as a last resort. Maintenance Therapy It is important to ensure that adequate maintenance therapy is instituted simultaneously with the emergent treatment to prevent relapse of SE.

Special Situations Certain medical conditions can present with SE. Treatment of Underlying and Precipitating Causes Comprehensive management of SE includes treatment of precipitants and causes such as noncompliance with AED therapy, acute infections, high fever, hypoglycemia, electrolyte imbalance, organ dysfunction, drug intoxication, poisoning, alcohol withdrawal, excess use of alcohol, stroke, trauma, and hypertensive encephalopathy.

Complications Patients with SE are prone to several medical complications. Pitfalls in Management SE often fails to respond or gets protracted because of deficiencies in the management. Prognosis SE has a variable prognosis. Conclusions SE is a medical emergency that need to be evaluated and managed in a systematic manner. References 1. Long-term mortality after a first episode of status epilepticus. Epidemiology of status epilepticus. J Clin Neurophysiol. Gastaut H. A propos d' une classification symptomatologique des etats de mal epileptiques.

Les etats de mal epileptiques. Paris: Masson; Clinical and electroencephalographic classification of epileptic seizures. Brodie M. Status epilepticus in adults. The secondarily generalized tonic-clonic seizure: A videotape analysis. Determinants of mortality in status epilepticus. Status epilepticus. N Engl J Med.

Shorvon S. Status epilepticus: Its clinical features and treatment in children and adults. Cambridge, England: Cambridge University Press; The seizure has lasted at least 12 minutes now, so this is status epilepticus. No information is available about her past history.

The paramedics were unable to start an IV, but did administer one dose of IM midazolam en route…. Unlike simple seizures, which will resolve without any intervention and require clinical constraint to avoid overtreatment, status epilepticus is a medical emergency that requires immediate management.

If for some reason you are unable to get a level, just go ahead and treat empirically with D50W. Glauser ; Claassen ; Zaccara Glauser Usually this first dose will have already been given before the patient arrives. If an IV has not been started, I will immediately give intramuscular or intranasal midazolam.

Claassen Note : We frequently underdose benzodiazepines. I think it makes sense to stick to the weight based doses that we use in children, which means using larger doses than usual in adults 8 mg of lorazepam IV or 10 mg of midazolam IV.

This is the dose that was used in the classic Vetrans Affairs Cooperative study. Treiman Although people worry about respiratory depression, aborting the seizure probably results in less respiratory depression, despite the higher benzodiazepine dose. Glauser Note 2: Since originally publishing this post, I have thought a lot about the use of intranasal midazolam. Although we normally start with the ABCs, I mention airway after the first dose of benzodiazepine, because terminating seizure activity will often solve airway and breathing issues.

I place nasal trumpets bilaterally and apply a non-rebreather facemask in an attempt to provide some apneic oxygenation. Airway assessment and management is complicated in status. Although most patients can initially be managed without intubation, if there is any concern, or the patient is hypoxic, it is always appropriate to proceed with an RSI.

Brophy The management of status epilepticus requires vascular access. If there is no response 4 minutes after the first benzo, repeat the dose.

Glauser ; Claassen Eclampsia must be considered in any female of childbearing age before moving on to second-line medications.

Women in their third trimester should be relatively obvious, but eclampsia can occur up to 8 weeks postpartum, so you may need to treat empirically. Give magnesium 4 grams IV. Most published algorithms will have with phenytoin, fosphenytoin, or levetiracetam as the second-line agent. Also, phenytoin is generally contraindicated for toxicologic seizures and I rarely have enough information in the first 15 minutes to exclude overdose. Marik ; Glauser ; Farkas I think phenytoin is still a good choice, but it is contraindicated in toxicologic seizures, and I avoid it in patients with known cardiovascular issues.

My second line drug is propofol 1. There is an accompanying post that discusses the logic behind suggesting early aggressive use of anesthetic agents ie propofol that can be found here. Note: There is probably better evidence for using phenobarbital in this early anesthetic approach, especially after a new RCT from South Africa. Burman However, I continue to use propofol because it is used far more frequently in the departments where I work, and I think it will be quicker and more reliable to give in the context of a critically ill patient.

Keep the phenytoin or whatever conventional anticonvulsant you chose running, even if the seizure is aborted by the propofol. Most patients requiring second line anticonvulsants will require advanced airway management.

When using propofol as my second line agent, I assume every patient will need to be intubated. Because status epilepticus precludes adequate preoxygenation and denitrogenation , these patients are at high risk of rapid desaturation. The patient can be resuscitated with the LMA in place and transitioned to an endotracheal tube when stable. This is a point of significant debate. Paralytics will mask ongoing convulsions, and may increase the rate of nonconvulsive status epilepticus.

Thus, this is one of the few scenarios in emergency medicine that a sedative only intubation makes sense. That being said, sedative only intubation is technically difficult, and status patients will be even more difficult because of high rates of trismus and rapid desaturation, so for the average provider myself included a standard RSI probably makes the most sense. If a paralytic is used, EEG monitoring is essential as soon as possible and that might be a while in most settings after intubation.

Succinylcholine could cause hyperkalemia if seizures have been extremely prolonged and rhabdomyolysis has already developed or if there is an underlying neurologic disorder.