Status Epilepticus

BACKGROUND

Description

Status epilepticus is defined as more than 30 minutes of (1) continuous seizure activity or (2) two or more sequential seizures with out full recovery of consciouslness between seizures. Seizures may be convulsive or non-convulsive. The longer the seizure continues, the greater the likelihood of an adverse outcome such as neurologic damage or death. (Return to the index to view a document on the management of epilepsy.)

Possible Causes

Anticonvulsant medication change or withdrawal (most common cause) or non compliance
Fever
Cerebrovascular abnormalities
Metabolic Disorders
Infections (meningitis)
Trauma
Hypoxic-ischemic injury (drowning, smoke inhalation, nonaccidental trauma)
Tumors
Unknown
Toxins (cocaine, theophyline, etc)

Prevalence

Incidence : 18-50 cases per 100,000 persons/year Approx. 260,000 new/recurrent cases of status epilepticus per year.

Epilepsy affects 1:200 individuals in the general population and 1:4 individuals with mental retardation. It is estimated that up to 20% of people with epilepsy experience status epilepticus. About 75% of patients who experience status epilepticus are under the age of 5. Status epilepticus is less frequent in individuals whose epilepsy is well-controlled.

Possible Associations

Epilepsy
Mental retardation
Anoxic brain damage
Apnea
Aspiration
Head trauma
Hypercarbia
Hypoxia
Hypoglycemia
Pain
Lactic and respiratory acidosis
Minor soft tissue trauma
Neurologic damage
Death

MEDICAL MANAGEMENT CONSIDERATIONS

Note: These considerations are in addition to the normal medical care provided to an individual without status epilepticus.

I. Treatment by Primary Care Physician or Group Home Staff

Note: Emergency services should be contacted if there is any concern for the well-being of the patient. Because no one can accurately predict whether a seizure will last twenty to thirty minutes or more (which is a requirement for the diagnosis of status epilepticus), and because appropriate emergency care may not be accessible due to distance or time, caregivers should be prepared to administer rectal diazepam (Diastat). Diastat is appropriate for epileptic patients ages 2 and over who have a seizure lasting longer than five minutes.

0 to 5 minutes

Ensure safety of patient
Monitor vital signs
Deliver oxygen if available
Place patient on side to prevent aspiration

6 to 10 minutes

Give Diastat if age 2 or over (only once)
Consider giving benzodiazepine
Document time of seizure, time medication is administered, and seizure characteristics

Refer to emergency care if any of the following occur:

Seizures are different from patient’s usual episodes;
Patient does not wake up within 10 to 15 minutes after cessation of convulsion;
Seizures continue for 10 minutes after Diastat is given; or
You are alarmed or confused at any time during evaluation and treatment.

II. Treatment by Emergency Care Physician

Note: The noted times may not be applicable in the emergency room setting. Many tests and procedures may occur concurrently, such as IV access, medication administration, etc.

Ensure safety of patient
Monitor cardiopulmonary function and vital signs
Place patient on side to prevent aspiration
Perform complete physical exam
Assess oxygenation with oximetry or periodic arterial blood gas determinators
Deliver oxygen by nasal cannula or mask
Document time of seizure and seizure characteristics
Establish an intravenous line
Draw venous blood samples and assess glucose, serum chemistry, electrolytes, blood urea nitrogen, and drug levels
Obtain urine drug screen
Initiate cardiac monitoring
Administer glucose if necessary
Administer lorazepam or diazepam
May administer diazepam up to twice more if seizure persists
If seizure persists, administer phenytoin or fosphenytoin
Monitor cardiopulmonary function and blood pressure
Document time all medications administered

31 to 45 minutes

If seizure persists, administer phenobarbital
May administer phenobarbital in 5-10 mg/kg doses up to a maximum of 30-40 mg/kg
Anticipate intubation
Monitor cardiopulmonary function and blood pressure
Monitor EEG

>45 minutes

Transfer to ICU setting
Patient should be intubated and ventilated
Adults: administer general anesthetic: pentobarbitol, phenobarbital, profpofol, midazolam, or thiopental
Children: administer pentobarbital followed by phenobarbital
Monitor cardiopulmonary function and blood pressure
Monitor EEG

After seizure stops

To prevent recurrent status, administer phenobarbital to neonatal patients; phenytoin or fosphenytoin to pediatric or adult
Obtain brain scan (CT or MRI) and assess for possible mass lesion
Evaluate for lumbar puncture
Perform liver function studies

III. Ongoing Management

(Return to the index to view a general epilepsy document)

Assess family medical history and investigate possible etiologies
Maintain a thorough medical history of seizure frequency and characteristics
Use EEG to study the disorder
Carefully monitor levels, effectiveness and side effects of all medications
Watch for changes in intellectual skills
Ensure that all caregivers know what to do in the event of seizure or status epilepticus
Recommend regular exercise, plenty of rest and efforts to reduce stress
Advise to avoid taking a bath in a tub or swimming without family or a friend present
Advise to avoid life-endangering situations (scuba diving, parachuting, two-wheeled vehicles on busy roads, etc.)

REFERENCES

Peer-reviewed Journal Articles/Academies

Cruse, Robert P. (2005) Treatment of Status Epilepticus. Cleveland Clinic Journal of Medicine, 56(2), 254-259.

Kaplan, P.W. (2005). The Clinical Features, Diagnosis and Prognosis of Nonculvulsive Status Epilepticus. The Neurologist, 11(6), 348-361.

Walker, M.C. (1998). The Epidemiology and Management of Status Epilepticus. Current Opinion in Neurology 11(2), 149-154.

Lowenstein, D.H. (2003). Treatment Options for Status Epilepticus. Current Opinion in Pharmacology, 3(1), 6-11.

Sabo-Graham, R., Seay, A.R. (1998). Management of Status Epilepticus in Children. Pediatrics in Review, 19(9), 306-309

Treatment of Convulsive Status Epilepticus: Recommendations of the Epilepsy Foundation of America’s Working Group on Status Epilepticus.(1993) Journal of the American Medical Association, 270(7), 854-859.

Special Interest Groups/Other Publications

Appleton, R. et al. (2000). The Treatment of Convulsive Status Epilepticus in Children: The Status Epilepticus Working Party. Archives of Disease in Childhood, 83(5), 415-419..

Gibson, J.R. Jr. (1999). Status Epilepticus. In M.R. Dambro(Ed.) Griffith’s 5 Minute Clinical Consult. (pp. 1006-1007) Baltimore: Lippincott Williams & Wilkins.

Gordon, A. et al. (2005). AREA OF FOCUS VI: Epilepsy and Status Epilepticus. Retrieved on March 2, 2006 from http://www.ninds.nih.gov/about_ninds/plans/disparities.htm#epilepsy

Huff, S. (2005). Status Epilepticus. eMedicine. Retrieved March 2, 2006, from http://www.emedicine.com/EMERG/topic554.htm

Kastner, T. (1998). Group Home Staff Instructions for the Use of Diastat (Rectal Valium) To Control Seizures. Unpublished document.

Kelley, R.E. (1997). Status Epilepticus: Diagnosis and Management. Louisiana State University Medical Center website. Retrieved on March 2, 2006 from http://lib-sh.lsuhsc.edu/fammed/intern/statepil.html

Prasad, A. et al. (2001) Propofol and Midazolam in the Treatment of Refractory Status Epilepticus. Epilepsia, 42(3), 380-386.

Rossetti, A. et al. (2004). Propofol Treatment of Refractory Status Epilepticus: A Study of 31 Episodes. Epilepsia, 45(7), 757-763.

Sinclair, D. (1997). Status Epilepticus. University of Alberta Department of Pediatrics web site. Retrieved on March 2, 2006 from http://www.ualberta.ca/~pediatri/clinical/statepi.htm

Smith Consultant Group and McGowan Consultants. (1998). Epilepsy. In M. Ligon Snyder,(Ed.) Health and Wellness Reference Guide. (pp.197-214).Neri Productions, State of Tennessee Commission on Compliance.

Young, G.M. (1998). Pediatrics Status Epilepticus, eMedicine, Retrieved on March 2, 2006 from http://www.emedicine.com/emerg/topic404.htm

RESOURCES FOR FAMILIES

American Epilepsy Society,

http://www.aesnet.org

Bowman Gray School of Medicine Epilepsy Information Service, 800-642-0500

California Department of Developmental Services, 916-654-1690,

http://www.dds.ca.gov

California Regional Centers, 915-654-1958,

http://www.dds.ca.gov/rc/RCInfo.cfm

Epilepsy Foundation of America, 800-332-1000,

http://www.efa.org

International Bureau for Epilepsy

http://www.ibe-epilepsy.org/

Epilepsy Society of San Diego County, 619-296-0161

Exceptional Parent Magazine, 800-247-8080,

http://www.eparent.com

March of Dimes Birth Defects Foundation, 914-428-7100,

http://www.marchofdimes.com/

New York Hospital Epilepsy Center,

http://www.nym.org/services/epilepsy/epilepsy.html

ADVISORY COMMITTEE

Theodore A. Kastner, M.D., M.S.

Felice Weber Parisi, M.D., M.P.H.

Mary Ann Lewis, Dr.P.H., R.N., F.A.A.N.

Jaime D. Mejlszenkier, M.D., F.A.A.N

Terrance D. Wardinsky, M.D.

PUBLICATION INFORMATION

Funded by a grant from the California Department of Developmental Services

For more information, contact:

Center for Health Improvement

1330 21st Street, Suite 100

Sacramento, CA95814

(916) 901-9645

This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.