Status epilepticus





This chapter will review recommendations from the 2012 Neurocritical Care Society and 2016 American Epilepsy Society Guidelines.


Definition


Status epilepticus is defined as 5 min of continuous seizures, or two seizures without regaining consciousness in between for more than 5 min.


Common etiologies


See Table 15.1 .



Table 15.1

Typical Etiologies of Status Epilepticus in the Intensive Care Unit

Adapted from Brophy GM, Bell R, Claassen J, et al.; Neurocritical Care Society Status Epilepticus Guideline Writing Committee. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care . 2012;17(1):3–23.









MOST COMMON LESS COMMON



  • Drug Toxicity




    • Amphetamines



    • Cocaine



    • Tricyclics




  • Drug Withdrawal




    • Barbiturates



    • Benzodiazepines



    • Ethanol



    • Opiates




  • Metabolic




    • Hypoglycemia



    • Hypoxia



    • Uremia



    • Liver failure





  • Ischemic




    • Stroke



    • Cardiac arrest




  • Traumatic




    • Intracranial hemorrhage



    • Intracranial hypertension




  • Infectious




    • Abscess



    • Meningoencephalitis



    • Septic emboli




  • Hematologic




    • Disseminated intravascular coagulopathy



    • Thrombotic thrombocytopenia purpura




Management





  • Treatment algorithm ( Fig. 15.1 )




    Figure 15.1


    Treatment Algorithm for Status Epilepticus by 2016 American Epilepsy Society Guidelines.

    ECG, Electrocardiogram; EEG, Electroencephalography; IV, Intravenous Level A, Established as effective; Level B, Probably effective; Level U, Data inadequate or insufficient.

    From Glauser T, Shinnar S, Gloss D, Arya R, Bainbridge J, Bare M, Bleck T, Dodson WE, Garrity L, Jagoda A, Lowenstein D, Pellock J, Riviello J, Sloan E, Treiman DM. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Currents. 2016;16(1):48-61.





  • Pharmacotherapy ( Table 15.2 )



    Table 15.2

    Drug Regimens for Generalized Status Epilepticus

    Adapted from Brophy GM, Bell R, Claassen J, et al.; Neurocritical Care Society Status Epilepticus Guideline Writing Committee. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care . 2012;17(1):3–23; Glauser T, Shinnar S, Gloss D, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Currents . 2016;16(1):48–61.










































































































    DRUG USUAL DOSE PD/PK METABOLISM COMMENTS
    First-Line Therapy (Emergency): Benzodiazepine



    • Lorazepam




    • 0.1 mg/kg IV (up to 4 mg/dose), MR in 5–10 min



    • NTE: 2 mg/min




    • Onset: 10 min



    • Duration: 6–8 h



    • Half-life: 14 h




    • Hepatic




    • IV formulation contains propylene glycol



    • ADR: sedation, hypotension, respiratory depression




    • Midazolam




    • 0.2 mg/kg IM up to 10 mg/dose




    • Onset: 15 min



    • Duration: up to 6 h



    • Half-life: 3 h




    • Hepatic; active metabolite




    • Short duration with IV



    • ADR: sedation, hypotension, respiratory depression




    • Diazepam




    • 0.15 mg/kg IV up to 10 mg/dose, MR in 5 min



    • NTE: 5 mg/min



    • If IV not available, 0.2–0.5 mg/kg PR up to 20 mg/dose




    • Onset:




      • IV: 1–3 min



      • PR: 2–10 min




    • Duration: 15–30 min



    • Half-life:




      • IV: parent 33–45 h; desmethyl-diazepam: 100 h



      • PR: parent 45–46 h; desmethyl-diazepam: 71–99 h





    • Hepatic



    • Active metabolites: N-desmethyl-diazepam, temazepam, and oxazepam




    • IV formulation contains propylene glycol



    • Not recommended as first-line therapy due to short duration of seizure control



    • ADR: sedation, hypotension, respiratory depression

    Second-Line Therapy (Urgent): Initiate After Benzodiazepine if Seizures Persist or if a Maintenance Needed



    • Valproate




    • 20–40 mg/kg IV, up to 3000 mg/dose




    • Time to peak: at the end of 1 h infusion



    • Half-life: 9–19 h




    • Hepatic




    • Therapeutic level: 50–100 mcg/mL




    • Phenytoin




    • 20 mg/kg IV, may give additional 5 mg/kg 10 min after LD



    • NTE: 50 mg/min




    • Onset: 0.5–1 h



    • Half-life: 7–42 h




    • Dose-dependent (Michaelis-Menten) PK




    • Enzyme inducer; several DDIs



    • IV formulation contains propylene glycol and ethanol



    • ADR: hypotension, arrhythmia, phlebitis, purple glove syndrome, hepatotoxicity



    • Only compatible in saline




    • Fosphenytoin




    • 20 PE mg/kg IV, may give additional 5 mg/kg 10 min after LD



    • Max: 1500 mg PE/dose



    • NTE: 150 mg/min



    • May also give IM




    • Time to peak: 15 min



    • Half-life:




      • Fosphenytoin: 15 min



      • Phenytoin: 12–29 h





    • Hepatic; fosphenytoin is rapidly converted to phenytoin via hydrolysis




    • Enzyme inducer; several DDIs



    • ADR: hypotension, arrhythmia, hepatotoxicity




    • Phenobarbital




    • 20 mg/kg IV, may give additional 5–10 mg/kg 10 min after LD



    • NTE: 100 mg/min




    • Onset: 5 min



    • Duration: >6 h



    • Half-life: 53–118 h




    • Hepatic




    • IV formulation contains propylene glycol



    • Enzyme inducer



    • ADR: sedation, hypotension, respiratory depression




    • Levetiracetam




    • 1–3 g or 60 mg/kg IV up to 4500 mg/dose



    • NTE: 5 mg/kg/min




    • Time to peak: 1 h



    • Half-life: 6–8 h




    • Enzymatic hydrolysis (24% of dose)



    • Renal excretion (66% as unchanged and 27% as inactive metabolites)




    • ADR: sedation, paradoxical excitation, irritability



    • Renally eliminated

    Third-Line Therapy (Refractory): Initiate if Seizures Persist After First- and Second-Line Therapy



    • Midazolam high-dose infusion




    • 0.05–0.2 mg/kg/h




    • Onset: 3–5 min



    • Half-life: 1.8–6.8 h (prolonged in renal failure, cirrhosis, CHF, obesity, and elderly)




    • Hepatic, active metabolite




    • Requires intubation before starting therapy



    • ADR: sedation, hypotension, respiratory depression




    • Pentobarbital




    • 25 mg/kg LD followed by 0.5–5 mg/kg/h




    • Onset: 3–5 min



    • Half-life: 15–50 h (dose dependent)




    • Hepatic




    • Requires intubation before starting therapy



    • IV formulation contains propylene glycol



    • Enzyme inducer; several DDIs



    • ADR: sedation, hypotension, respiratory/cardiac depression, paralytic ileus, immunosuppression




    • Propofol




    • 20–200 mcg/kg/min



    • Titrate by 5 mcg/kg/min q5min




    • Onset: 9–51 s



    • Half-life: Biphasic:




      • Initial: 40 min



      • Terminal: 4–7 h (after 10-day infusion, may be up to 1–3 days)





    • Hepatic




    • Requires intubation before starting therapy



    • ADR: sedation, hypotension, respiratory depression, pancreatitis, cardiac failure, rhabdomyolysis, metabolic acidosis, propofol infusion syndrome



    • Lipid formulation provides 1.1 kcal/mL




    • Valproate




    • 20–40 mg/kg IV, may give additional 20 mg/kg 10 min after LD



    • NTE: 5 mg/kg/min




    • Time to peak: at the end of a 1 h infusion



    • Half-life: 9–19 h




    • Hepatic




    • For nonintubated



    • Many DDIs, avoid in patients with a TBI



    • ADR: hyperammonemia, thrombocytopenia, hepatotoxicity, pancreatitis




    • Lacosamide




    • 200–400 mg IV



    • NTE: 200 mg/15 min




    • Time to peak: 1–4 h



    • Half-life: 13 h




    • Renal excretion (95%)




    • For nonintubated



    • ADR: dizziness, bradyarrhythmia, PR prolongation, hypotension




    • Topiramate




    • 200–400 mg PO/NG ×1 then 300–1600 mg/day PO/NG (divided two to four times daily)




    • Time to peak: 2 h



    • Half-life: 19–23 h




    • Renal excretion (70% as unchanged drug)




    • For nonintubated



    • ADR: metabolic acidosis



    • No IV formulation available




    • Ketamine




    • 0.5–5 mg/kg/h




    • Onset: 30 s



    • Half-life:




      • α: 10–15 min



      • β: 2.5 h





    • Hepatic




    • ADR: excitation, hypertension, possible neurotoxicity, hallucinations

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Feb 28, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Status epilepticus

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