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Status Epilepticus

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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:
  • U&Es:
  • LFTs:
    • May be deranged in alcohol-use disorder
  • CRP:
    • May be elevated in infection
  • Clotting screen:
  • 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

Prognosis

  • Acute aetiologies such as stroke are associated with a worse prognosis
  • A longer duration of symptoms is associated with a worse prognosis

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