Status Epilepticus is a medical emergency. Outcome correlates with rapidity of treatment and response, and with underlying etiology. Protocols provide a useful outline and checklist for treating physicians, and outcomes have been shown to be better in centers that utilize written protocols for evaluation and treatment. All protocols, however, should be used with caution and modified as clinical circumstances dictate.
INTERVENTIONS |
Check as completed |
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0 - 30 Minutes |
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Initial rapid assessment: Airway, Breathing, Circulation |
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0 min. |
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Record Vital Signs |
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1 min |
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Monitor: O2 SATURATION, EKG |
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2 min. |
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Establish IV access and have bloods sent: |
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2 -10 min. |
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CBC, Lytes, BUN/Cr, Glucose, Ca, Mg, P04, LFTS, AED levels, Toxicology screen, ABG. |
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THIAMINE, 100 MG IV |
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5-10 min. |
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50% DEXTROSE, 50 CC IV |
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LORAZEPAM, 0.1 MG/KG IV (<2 MG/MIN.) |
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5-10 min. |
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FOSPHENYTOIN, 20 MG/KG IV (150 MG/MIN.) or PHENYTOIN (20 MG/KG @ 50 MG/MIN) |
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10-20 min. |
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Begin concurrently with benzodiazepine (above) |
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Monitor EKG, Check BP Q 120 sec |
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FOSPHENYTOIN, ADDITIONAL 10 MG/KG IV (150 MG/min.) or PHENYTOIN (10 MG/KG @ 50 MG/MIN) |
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30 - 40 min. |
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Monitor EKG, Check BP Q 60 sec |
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| May use VALPROIC ACID (DEPACON) 30 MG/KG IV (150 MG/min.) or LEVETIRACETAM (KEPPRA) 50 MG/KG IV (100 mg/min) as alternatives when FOSPHENYTOIN or PHENYTOIN is contraindicated. See references below. | |||
30 – 60 Minutes |
Send repeat Phenytoin level -20 min. after load |
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PHENOBARBITAL 20 MG/KG (75 mg/min) |
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40 min |
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INTUBATE (If not done previously) |
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50 min. |
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INITIATE EEG MONITORING |
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Contact Neurologist/Epilepsy Specialist MGH Epilepsy Service: 617 726-3311 |
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Options for next step include: |
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> 60 Minutes |
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MIDAZOLAM 0.2 MG/KG IV (loading dose) (Preferred if BP is unstable) |
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50-60 min. |
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Titrate dose (0.1-0.4 mg/kg/hr) to stop electrographic and clinical seizures |
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Use fluid or pressor to support BP if needed. |
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PENTOBARBITAL, 5 MG/KG IV |
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50-60 min. |
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Titrate dose (0.3-9 mg/kg/hr, avg=4 mg/kg/hr) to maintain burst suppression on EEG. |
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Use fluid to support BP if needed, add pressor only if fluid fails or not clinically advisable. |
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PROPOFOL, 1-2 mg/kg load, 2-10 mg/kg/hr maintenance drip to stop clinical and EEG seizures or maintain burst suppression on EEG. |
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50-60 min. |
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OBTAIN CT SCAN (If clinically indicated) |
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Correct underlying cause of Status Epilepticus |
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3-48 hours |
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Adjust the principal anticonvulsants to therapeutic effect |
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24 hours |
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Taper Midazolam, Pentobarbital or Propofol after above complete |
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24-48 hours |
CONCURRENT EVALUATIONS (Beginning at the onset of management)
History, Exam, check labs:
STAT Head CT (MGH: 6-6760 BWH: 7213)
Cool patient if febrile
Consider Antibiotics & LP, especially if febrile or not known epileptic
Notes
Potential indications for urgent EEG or continuous EEG monitoring:
Question of non-epileptic status (pseudo-status)
- Question of absence vs. complex partial status epilepticus
- Failure to regain normal consciousness within a reasonable time after apparent cessation of seizure activity
- Monitoring of anesthetic suppression of epileptic activity (burst-suppression interval)
- All requests for urgent EEG and monitoring should be discussed with Epilepsy Fellow on call (Page through Partners or 726-3311).
REFERENCES:
Safety and pharmacokinetics of intravenous levetiracetam infusion as add-on in status epilepticus.
Uges JW, van Huizen MD, Engelsman J, Wilms EB, Touw DJ, Peeters E, Vecht CJ.
Epilepsia. 2009 Mar;50(3):415-21. Epub 2008 Nov 17.
PMID: 19054418
Sodium valproate vs phenytoin in status epilepticus: a pilot study.
Misra UK, Kalita J, Patel R.
Neurology. 2006 Jul 25;67(2):340-2.
PMID: 16864836
Last Modified 7/6/09