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CDHB

Generalized Convulsive Status Epilepticus

Definition

• Continuous generalized motor seizure activity, or intermittent generalized motor activity with no recovery of consciousness, lasting 30 minutes or more.

Pre-status

Pre-status is a phase of accelerating seizures that may last hours or days, and that heralds status in many patients. Prompt treatment at this stage can prevent status. Consider rectal diazepam or buccal midazolam. Address potential causes as below.

Pseudostatus

Suspect this if convulsive movements are tremorous or thrashing, rather than jerking, and if the patient’s sat.O₂ remains high despite apparent prolonged seizure activity.

Common causes of convulsive status epilepticus

• Patients on anticonvulsant treatment for epilepsy:
  • Non-compliance, withdrawal or change of anticonvulsants.
  • Non-CNS infection.
• New presentation of seizures:
  • Acute cerebral insult (head injury, stroke, hypoxia)
  • CNS infection (encephalitis, meningitis)
  • Brain tumour
  • Benzodiazepine or alcohol abuse/withdrawal
  • Drug toxicity
  • Metabolic disturbance (low blood sugar, calcium)

Immediate treatment and investigation

• Support:
  • Check pulse, BP and airway.
  • 100% oxygen.
  • IV line.
  • Monitor pulse, BP, respiration and sat.O₂.
  • Bag patient between convulsive movements if sat.O₂ drops.
• Contact ICU informing them that the patient may require urgent transfer in 10-15 minutes if initial treatment does not control the seizures.
• Drugs:
  • Give lorazepam 4 mg IV over 2 minutes.
  • If seizures continue after a further 2 minutes, give:
    • Either phenytoin 15 mg/kg IV in 100 mL sodium chloride 0.9% at a rate of 50 mg/minute, max 25 mg/minute in the elderly. Can cause hypotension, bradycardia, and arrhythmias. Check pulse and respiratory rates and BP every 5-10 minutes. Do a continuous ECG recording for at least an hour post infusion.
    • Or sodium valproate 30 mg/kg IV over 5 minutes. Check pulse and respiratory rates and BP every 5-10 minutes.
• Contact ICU re transfer if seizures continue, and/or if there are concerns about the patient’s airway and/or breathing.
• Once there, management will be in conjunction with ICU staff, but will include intubation, ventilation and further drugs to stop the seizures such as midazolam, phenobarbitone, and propofol.
• Tests:
  • Capillary blood glucose test - if below normal range give thiamine 100 mg IV and then 50 mL of 50% glucose (dextrose).

Note: The choice between phenytoin and valproate is dictated by the Consultant responsible for the patient. At the present time both are probably equally effective in controlling status. Most senior staff are well acquainted with giving phenytoin, but valproate may be easier to give with fewer complications. Data supporting the use of valproate at this dose rate is relatively small, and an international RCT is underway to compare these two drugs, and levetiracetam, for the control of status (Epilepsia 2013;54: S6 89-92).

Measures to take next

• If the seizures have stopped, seek Neurology advice on further management.
• CBC, Na, K, Ca, Mg, blood glucose.
• Give thiamine 100 mg IM or IV.
• If the patient is on anticonvulsants for epilepsy, give their total daily dose of all their drugs as soon as practicably possible, IV or NG if IV not available. Check levels pretreatment. If a drug has recently been withdrawn, reload, and reinstate the former dose. Chart usual daily anticonvulsant drug dosages.
• The Neurology consultation will provide advice on imaging, CSF examination, aciclovir and further anticonvulsant therapy.

Topic Code: 1515