Overview
Status epilepticus describes a seizure that continues for more than 5 minutes or seizures that occur one after another with no recovery in between. It is a medical emergency and if left untreated, it can lead to irreversible brain damage or death.
Epidemiology
- Incidence is higher in poorer communities
- It recurs in 1/3 of patients
Risk Factors
- History of epilepsy
- Poor adherence to antiepileptic drugs
- Alcohol-use disorder
- Stroke
- Metabolic disturbances e.g. dehydration, hypoglycaemia, electrolyte dysfunction
- Recreational drug use and withdrawal
Differential Diagnoses
Psychogenic non-epileptic seizure (PNES)
- In PNES, seizures have a fluctuating course
- Movements may be asynchronous
- There may be a quick recovery and no impairment in memory regarding the seizure
Investigations
All patients
Immediate management
- Investigations and management should be carried out at the same time
- Glucose:
- For hypo-/hyperglycaemia
- Blood gases:
- Abnormalities can cause seizures
- FBC:
- Alcohol-use disorder – raised mean cell volume
- U&Es:
- Hyponatraemia, hypernatraemia, and uraemia can cause seizures
- LFTs:
- May be deranged in alcohol-use disorder
- CRP:
- May be elevated in infection
- Clotting screen:
- Identifies coagulopathy
- Anticonvulsant drug levels:
- May be normal or may show subtherapeutic levels
Other investigations
- CT head:
- If no previous history of epilepsy/focal neurological deficits/refractory status epilepticus
- Lumbar puncture:
- If CNS infection/inflammation suspected
- Toxicology screen:
- If illicit substance use suspected
Diagnosis is clinical. Status epilepticus is a medical emergency and must be managed immediately.
Management
In the community
- 1st-line: buccal midazolam or rectal diazepam + call ambulance
In hospital
- 1st-line: ABCDE assessment + IV lorazepam
- Repeat IV lorazepam once after 5–10 minutes
- 2nd-line: if established (ongoing) status epilepticus: IV levetiracetam, phenytoin, or sodium valproate
- Levetiracetam may be quicker to administer and has relatively fewer side effects
- If refractory (>45 minutes from onset): immediate ICU transfer + general anaesthesia or phenobarbital
Monitoring and Patient Advice
Monitoring
- Patients should be regularly monitored in status epilepticus. The GCS and vital signs are often used for monitoring patients.
- A score that is 8 or less should be considered for airway management (intubation)
- During acute treatment, antiepileptic drug levels should be monitored
Patient Advice
- Patients should be educated on the risks of status epilepticus and should try to adhere to treatment as best as possible
- Patients should avoid alcohol/drug misuse and should be helped with this
Complications
- Focal neurological deficits
- Memory problems
- Behavioural problems
Prognosis
- Acute aetiologies such as stroke are associated with a worse prognosis
- A longer duration of symptoms is associated with a worse prognosis