Treat Status Epilepticus as a Medical Emergency
Laith R. Altaweel MD
Status epilepticus is a medical emergency that requires immediate recognition and treatment. It is defined as a series of seizures that occur without recovery of underlying neurologic function. There are many causes of status epilepticus, which may be related to an underlying epileptic disorder or secondary to an acute neurologic insult (Table 213.1). In the ICU setting, up to 8% of patients experience this condition with an associated mortality that can be as high as 40%.
Watch Out For
There are many different presentations of status epilepticus. It can present with generalized bilateral involvement of skeletal muscles and loss of consciousness. It may begin as a focal seizure on one side, which then generalizes to the contralateral side, with loss of consciousness or, it may be nonconvulsive in nature. Status epilepticus can be confirmed by an electroencephalogram (EEG), but treatment should not be delayed pending an EEG result. The EEG can be used to confirm both clinically apparent and subclinical status epilepticus.
What to Do
When a patient is experiencing a seizure, fundamental principles of advanced life support need to be applied. The patient should receive supplemental oxygen and should be intubated if the airway is compromised. Blood pressure, heart rate, and oxygen saturation need to be assessed. Intravenous (IV) access should be obtained and serum chemistry profiles, complete blood count, and serum glucose level assessed. If the glucose level is low, dextrose 50% (D50) should be administered. Glucose in the absence of thiamine should not be given unless hypoglycemia is documented since it can precipitate Wernicke encephalopathy in thiamine-deficient patients. Alternatively, patients can be given 100 mg of thiamine before or with glucose administration. Once IV access is obtained, intravenous benzodiazepines, preferably lorazepam (0.1 mg/kg) should be administered. It is important to note that administration of benzodiazepines may further compromise the patient's mental and respiratory status. Therefore, preparation for intubation and mechanical ventilation should be done. If the seizure persists,
phenytoin 20 mg/kg should be given and repeat doses up to 30 mg/kg should be administered. The blood pressure, which may initially be elevated, can decrease with the administration of anticonvulsant therapy or after 15 to 30 minutes of continuous seizure activity due to impaired cerebrovascular autoregulation. Intravenous fluids and vasopressor support should be administered to maintain adequate blood pressure.
TABLE 213-1 CAUSES OF STATUS EPILEPTICUS
Prior seizure history
No prior seizure history
Central nervous system infection
Central nervous system tumor
Less common etiologies
In status epilepticus cerebral injury results from prolonged electrical discharge that occurs. If seizures persist in spite of the previously described therapy, then the patient should receive intravenous phenobarbital, continuous infusion of intravenous benzodiazepine, or propofol. Continuing seizures that fail to respond should prompt an evaluation of the sodium level. Hyponatremia may cause status epilepticus that fails to respond to conventional anticonvulsant therapy. For these patients, empiric 3% saline may be indicated to stop the seizures. In addition, hypomagnesia may be the cause of seizures and status epilepticus in transplant patients because of the magnesium-depleting effect of most immunosuppression regimens. The experienced practitioner will realize that normal serum magnesium is not indicative of total body magnesium load. Many transplant centers administer IV magnesium empirically when any transplant patient seizures, regardless of serum levels.
Fink MP, Abraham E, Vincent JL, et al., eds. Textbook of Critical Care. 5th ed. Philadelphia: Elsevier Saunders; 2005:355â€“365.
Wyllie E, ed. The Treatment of Epilepsy: Practice and Principles. Philadelphia: Lippincott Williams & Wilkins; 2001:681â€“697.