Status Epilepticus

STATUS EPILEPTICUS

Status epilepticus is a neurological emergency with significant morbidity and mortality if not treated. Prolonged status epilepticus can lead to metabolic derangements, cardiac dysrhythmias, autonomic dysfunction, hyperthermia, rhabdomyolysis, pulmonary edema, aspiration, and permanent brain damage.

There has been ongoing debate about the length of time necessary before a seizure can be called status epilepticus. It had been 30 minutes at one point but is now about five minutes. Another operative definition is the presence of two or more seizures without recovery of normal consciousness in between. More worrisome is refractive status epilepticus, which involves seizures lasting 60 minutes or more in spite of benzodiazepine or other anticonvulsant therapy. Malignant status epilepticus is the most severe aspect of this, with seizures despite general anesthesia, often seen in adults who have encephalitis.

Ordinary cases of status epilepticus usually happen with preexisting epilepsy. Many will either have stopped taking their medications or will have low levels of anticonvulsive drugs in their system. CNS infections, including malaria, can cause status epilepticus. Less common causes are metabolic derangements, congenital brain diseases, anoxia, trauma, or drug/alcohol usage.

There are two basic stages of status epilepticus. The first state involves tonic-clonic activity, hyperglycemia, increased blood flow, elevated body temperature, salivation, and sweating. After thirty minutes of this, regulatory processes break down and cerebral blood flow decreases. There is systemic hypotension and increased intracranial pressure. The tonic-clonic activity may actually diminish. There is cerebral hypoglycemia, hypoxia, acidosis, and metabolic disturbances, such as hyponatremia, hyperkalemia, and hypokalemia. Blood pressure and cardiac output drops.

In treating the patient, manage their airway and start an IV. Give benzodiazepines or phenytoin to control seizures, thiamine, and glucose. The initial treatment of choice is IV lorazepam. The second-best treatment is IV fosphenytoin. Hypoglycemia must be urgently excluded and treated if present. Once the seizures have been controlled, blood