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THE MORNING REPORT

The Best in FOAM Education

  • Drew Nguyen, MD

Convulsive Status Epilepticus

Status Epilepticus Definition

  • ≥ 5 minutes of continuous seizures, or

  • ≥ discrete seizures without complete recovery of consciousness between each episode

General Algorithm

  • Secure Airway

  • 1st line agents: Benzodiazepines (lorazepam, midazolam, diazepam)

  • 2nd line anti-epileptics (levetiracetam, fosphenytoin, phenytoin, valproic acid)

  • 3rd line agents (ketamine, lacosamide, phenobarbital, propofol)

  • Test for causes

    • Finger stick glucose

    • metabolic panel (especially sodium)

    • Infectious sources (UA, CXR, WBC, blood cultures.)

    • Anti-epileptic drug levels

    • Consider B1 (alcohol use), B6 deficiencies (active TB treatment)

    • UDS

    • EEG

    • CT head

    • +/- MRI head

  • Supportive Medical Management

Common Causes

  • Acute symptomatic active epilepsy, chronic symptomatic active epilepsy, low anti-epileptic medication levels

  • Metabolic (electrolytes, anoxia, hypothyroidism, hyperthermia, uremia, Respiratory alkalosis, B1, B6, B12 deficiencies)

  • Malignancy, metastasis, primary tumors, radiation therapy, chemotherapy)

  • Infection/inflammation (meningitis, encephalitis, pneumonia, UTI, sepsis, autoimmune encephalitis, lupus cerebritis, anti NMDA receptor encephalitis, etc)

  • Vascular (CVA, Dissections, bleeding, cerebral venous thrombosis, PRESS, Eclampsia)

  • TBI

  • Drugs/Withdrawals (Bupropion overdose, TCA overdose, alcohol withdrawals, etc)

Medications Considerations

  1. First line agents: Benzodiazepines

  2. Lorazepam

  • 2-4mg IV (or 0.1 mg/kg), may repeat in 3-5m

  • Onset of action

  • IV: 2-3m

  • IM: 15-30m

  1. Midazolam

  • 2-4mg IV (or 0.1-0.2mg/kg), may repeat in 3-5m

  • 5-10mg IM (or 0.1-0.2mg/kg, maximum 10mg)

  • Onset of action

  • IV: 2-5m

  • IM: 5-15m

  1. Diazepam

  • 5-10mg IV, may repeat in 3-5m; maximum dose 30mg

  • Onset of action

  • IV: 0-1m

  1. Second line agents: Anti-epileptic drugs

  2. Levetiracetam

  • Loading dose 60mg/kg (maximum 4.5g)

  1. Fosphenytoin

  • Loading dose 20mg/kg (maximum 1.5g)

  • infusion rate not to exceed 150mg/m

  • if refractory, can consider additional 5-10mg/kg dose 10m after loading dose

  1. Phenytoin

  • Loading dose 20mg/kg (maximum 1.5g)

  • infusion rate not to exceed 150mg/m

  • if refractory, can consider additional 5-10mg/kg dose 10m after loading dose

  1. Valproic Acid

  • Loading dose 20-40mg/kg (maximum dose 3g)

  • infusion rate 10mg/kg/m

  • Works synergistically with lacosamide

  1. Third line agents: As 3rd line agents approach, strongly consider intubation

  2. Ketamine

  • Loading dose 1.5-4-5mg/kg dose; may repeat 0.5mg/kg every 3-5minutes followed by continuous infusion

  • Continuous infusion 0.1-1 mg/kg/hr (maximum 15mg/kg/hr)

  1. Propofol

  • Loading bolus 1-2mg/kg

  • continuous infusion 5-80mcg/kg/m

  • Side effect: propofol infusion syndrome, hypotension, respiratory depression

  1. phenobarbital

  • Loading dose 15-20mg/kg

  • infusion rate 50-100mg/m

  • Side effect: Hypotension, respiratory depression, ileus

  1. Lacosamide

  • Loading dose 200-400mg

  • infusion rate 400mg over 30m

  • Works synergistically with valproic acid

Notes -IV Speed of Onset: Diazepam (fastest) > Lorazepam > Midazolam (slowest)

-IM Speed of Onset: Midazolam (fastest) > Lorazepam > Diazepam (variable, unreliable)

-Excitotoxicity (downregulation of GABA receptors, up regulation of NMDA receptors) occurs as early as 15 minutes. DO NOT wait to administer benzodiazepines or give inappropriately low doses as the longer status epilepticus lasts, the less effective benzodiazepines are

-Give 2nd line anti-epileptic drug as initial treatment. All acute status epilepticus patients presenting to the ED will require loading dose of anti-epileptics regardless, so best to give it upfront


Supportive Medical Management

  • Rhabdomyolysis

    • Secondary to uncontrolled muscle contractions

    • check CPK, electrolytes, urine, EKG

    • Management: IVF

  • Neurogenic pulmonary edema

    • Secondary to fluid shifts

    • Management: respiratory support

  • Takotsubo cardiomyopathy

    • Secondary to sympathetic surge

    • bedside cardiac POCUS, formal echo, EKG, troponins, cardiology consult

    • Management: vasopressors, inotropic agents

  • Propofol infusion syndrome

    • check triglycerides


Andrew Nguyen, MD


References





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