Managing status epilepticus

In this video, we go through the step-by-step process for treating status epilepticus, where the process can go horribly wrong, and what to do if the patient remains unresponsive.

Gary R. Simonds, MD MHCDS FAANS
Gary R. Simonds, MD MHCDS FAANS
10th Sep 2021 • 4m read

Clinicians may feel overwhelmed at the prospect of treating status epilepticus (which can be fatal if left untreated), but it is actually pretty straightforward. In this video, we go through the step-by-step process for treating status epilepticus, where the process can go horribly wrong, and what to do if the patient remains unresponsive.

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Video transcript

When seizures persist for more than five minutes, or don't respond to first and second line anticonvulsants the patient is considered to be in status epilepticus. Untreated this can be fatal or leave a patient with permanent neurological injury. But don't panic, management of status epilepticus is relatively straightforward, and orderly and is usually very effective.

For a patient and status Epilepticus start by addressing the ABCs. Start nasal prong oxygen or mask oxygen. Start telemetry and pulse oximetry. Intubation may not be necessary initially if oxygenation is good. If not intubated, turn the patient on their side to diminish the chance of aspiration and protect the head and extremities.

Obtain a fingerstick glucose, obtain a complete blood count, metabolic profile with serum magnesium and calcium levels and liver function tests and arterial blood gases, also obtain anticonvulsant levels of appropriate and a toxicology screen. Place two large bore IVs and run maintenance normal saline. Give thymine 100 milligrams IV and dextrose 50 milliliters of 50% if a newly presenting patient has no known history of a seizure disorder or definitive etiology.

Hold dextrose if fingerstick glucose is within normal range or is elevated. Start first line anticonvulsants which are benzodiazepines, Lorazepam four milligrams IV, or midazolam 10 milligrams intramuscularly, repeat if no response within 30 seconds or so. If there is no response within a minute or so, to the second dose of a first line anticonvulsant go to a second line anticonvulsant.

Administer fosphenytoin 15 to 20 phenytoin equivalence that is PE per kg IV at a rate of less than 150 phenytoin equivalents per minute. Fosphenytoin is metabolized to phenytoin, so its dosage is given in phenytoin equivalence. Alternatively, you can administer phenytoin 15 to 20 milligrams per kilogram IV at a rate of less than 50 milligrams per minute. Note exceeding the recommended dosage rates of fosphenytoin or phenytoin risks severe cardiac complications.

A further dose of phenytoin, 10 milligrams per kilogram can be given at a rate of less than 50 milligrams per minute if additional medication is deemed necessary. For example, if there is continued seizing despite full administration of the first dose. Alternative second line anticonvulsants can be considered. But phenytoin and fosphenytoin remain the workhorses and status epilepticus because they have shown good efficacy with long term use. Alternative second line convulsions include levetiracetam, valproate and phenobarbital.

Phenobarbital is heavily sedating. Note that levetiracetam has become popular in many centers because of its excellent safety profile, but its efficacy in status Epilepticus has yet to be well established. A critical point to recognize is that the goal is to get the seizures under control within 30 minutes. So much work needs to be done simultaneously. As a first line medications are being given, the second line medications need to be ordered stat and drawn up.

As the second line medications are being administered, preparations should be made for intubation, and the administration of anesthetics. If the patient is not responsive to first and second line medications or is seizing for more than 30 minutes, go ahead and intubate the patient and start administering general anesthesia. Use either medazolam, .2 milligrams per kilogram IV load followed by .2 to .6 milligrams per kilogram per hour infusion or propofol, 2 milligrams per kilogram IV load followed by a two to five milligrams per kilogram per hour infusion.

Don't sit around for half an hour hoping the medications will take effect and then call the intubation team. Rather be prepared to go to intubation as soon as it's clear the seizures may not respond to first and second line medications. Don't fool around trying multiple medications from the first and second line groups, go with one of each and be prepared to intubate and administer anesthetics.

Most persistent seizures will respond to general anesthesia. If you are treating status Epilepticus with general anesthesia, you'll need to order a continuous EEG and you should consult neurology for support. On the other hand, those patients that have responded to level one or level two medications should undergo a standard EEG as soon as possible. For all patients sustaining status

Epilepticus an extensive evaluation for precipitating factors should be undertaken. As potential etiologies consider insufficient anticonvulsants, structural lesions such as hematomas, tumors, abscesses, metabolic derangement, systemic infections, medication interactions, and others. What about medical imaging? A noncontrast CT scan of the brain should be obtained to rule out an acute pathology. Stop the seizures first however. A pre and post contrast MRI of the brain should be obtained if one has not already been done so in the admission.

If a patient is found to be unresponsive and definitive etiology cannot be determined consider non convulsive status Epilepticus and order a 24 hour EEG. We have seen this entity with some frequency, mostly in the ICU setting, often with neurosurgical trauma patients. There are several other forms of status Epilepticus, such as focal motor status, absence status, and partial complex status. These are atypical and should be addressed upfront by a neurologist.