Status epilepticus: Difference between revisions
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==Background==
==Background==
*Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments or recurrent seizure activity without return to baseline mental status.<ref>Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9</ref><ref>Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8</ref> (Previous definitions used a 30-minute time limit)<ref>Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.</ref>
*Continuous seizure activity lasting >5 minutes, or ≥2 seizures without return to baseline<ref name="trinka">Trinka E, et al. A definition and classification of status epilepticus. Report of the ILAE Task Force. ''Epilepsia''. 2015;56(10):1515-1523. PMID 26336950.</ref>
*Overall mortality is high (22%)<ref name="Martindale">Martindale JL, Goldstein JN, Pallin DJ. Emergency department seizure epidemiology. Emerg Med Clin North Am. 2011 Feb;29(1):15-27.</ref>
*'''Time-sensitive emergency''' — mortality increases with duration of seizure
*Divided in generalized convulsive status epilepticus (GCSE) and nonconvulsive status epilepticus (NCSE)
*30-day mortality: 20% overall; higher in elderly and those with anoxic injury
**NCSE presents as an alteration in behavior associated with subtle changes (as twitching, blinking, eye deviation, aphasia, somatosensory findings) and continuous epileptiform discharges on EEG
*Refractory SE: seizures persisting despite two appropriate first-line agents
*Super-refractory SE: seizures persisting >24 hours despite anesthetic agents
 
==Etiology==
*Anti-epileptic drug (AED) non-compliance or subtherapeutic levels (most common in known epileptics)
*Acute CNS injury: [[Stroke (main)|stroke]], [[Traumatic brain injury|TBI]], [[Meningitis|CNS infection]], tumor
*Metabolic: [[Hypoglycemia|hypoglycemia]], [[Hyponatremia|hyponatremia]], [[Hypocalcemia|hypocalcemia]], hepatic failure, uremia
*Toxicologic: [[Ethanol withdrawal|alcohol withdrawal]], [[Benzodiazepine withdrawal]], [[Isoniazid toxicity|INH]], [[Organophosphate toxicity|organophosphates]], [[Cocaine toxicity|cocaine]], [[Tricyclic antidepressant toxicity|TCA]]
*[[Eclampsia]] (pregnant/postpartum patients)
*Febrile status epilepticus in children


==Clinical Features==
==Clinical Features==
*Seizure > 20 minutes. <ref>Brodie MJ. Status epilepticus in adults. Lancet. 1990 Sep 1; 336(8714):551-2.</ref>
*Generalized convulsive SE: continuous tonic-clonic activity, most readily recognized
*Presume status in current seizure > 5 minutes<ref>Lowenstein DH, Alldredge BK.  Status epilepticus.  N Engl J Med. 1998; 338:970-976</ref>
*Non-convulsive SE: subtle or no motor manifestations; persistent altered mental status
**Must maintain high suspicion in patients who remain altered after apparent seizure cessation
*Complications: [[Rhabdomyolysis|rhabdomyolysis]], [[Hyperthermia|hyperthermia]], lactic acidosis, aspiration, neuronal injury


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
*Clinical diagnosis
*'''Bedside glucose''' — immediately
*Labs: BMP (Na, Ca, Mg, glucose), CBC, AED levels, lactate, VBG, LFTs, toxicology screen
*CT head — once stabilized; evaluate for structural cause
*Continuous EEG — if available; essential to diagnose non-convulsive SE
*LP if infection suspected (after CT and when safe)
*CK, urinalysis (myoglobinuria) if prolonged seizure
 
==Management==
===Time 0-5 min: Stabilize===
*ABCs, supplemental O2, cardiac monitor, IV access
*'''Glucose''': check immediately; give '''D50W 50 mL IV''' (or D10W) if hypoglycemic
*Thiamine 100 mg IV before glucose if malnourished or alcoholic
*Position patient to prevent aspiration; suction as needed
 
===Time 5-20 min: First-Line — Benzodiazepines===
*'''[[Lorazepam]]''' 0.1 mg/kg IV (max 4 mg/dose), may repeat x1 in 5 min<ref name="silber">Silbergleit R, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. ''N Engl J Med''. 2012;366(7):591-600. PMID 22335736.</ref>
*If no IV access: [[Midazolam]] 10 mg IM (most effective prehospital per RAMPART trial)
*Alternatives: [[Diazepam]] 0.2 mg/kg IV (max 10 mg), or diazepam 20 mg PR
 
===Time 20-40 min: Second-Line — Anti-Epileptic Drug===
*'''[[Levetiracetam]]''' 60 mg/kg IV (max 4500 mg) over 15 min<ref name="kapur">Kapur J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus (ESETT). ''N Engl J Med''. 2019;381(22):2103-2113. PMID 31774955.</ref>
*[[Fosphenytoin]] 20 mg PE/kg IV (max rate 150 mg PE/min)
*[[Valproic acid]] 40 mg/kg IV (max 3000 mg) over 10 min
*ESETT trial: all three equally effective (~50% success each)


==Managment==
===Time >40 min: Refractory SE===
{{Seizure actively seizing management}}
*'''[[Intubation (main)|Intubation]]''' and continuous infusion of anesthetic agent:
**[[Midazolam]] 0.2 mg/kg IV bolus, then 0.1-2 mg/kg/hr
**[[Propofol]] 2 mg/kg IV bolus, then 2-10 mg/kg/hr (monitor for propofol infusion syndrome)
**[[Pentobarbital]] 5 mg/kg IV bolus, then 1-5 mg/kg/hr
*Continuous EEG monitoring required
*Target: burst-suppression for 24-48 hours
 
===Special Situations===
*[[Isoniazid toxicity|INH overdose]]: Pyridoxine (B6) gram-for-gram (empiric 5 g IV if dose unknown)
*[[Eclampsia]]: Magnesium sulfate 4-6 g IV
*[[Hyponatremia]]: Hypertonic saline (3%) 100 mL IV bolus


==Disposition==
==Disposition==
*Admit to ICU or intermediate level of monitored care depending on etiology, treatments and respiratory status
*ICU admission for all SE patients
 
*Neurology consultation
==External Links==
*Patients with rapidly terminated seizures who return to baseline may be managed on a monitored floor
*EM Nerd [http://emnerd.com/adventure-dancing-men/ Adventure of dancing men]


==See Also==
==See Also==
*[[Seizure]]
*[[Seizure]]
*[[Prehospital protocol pediatric seizure]]
*[[First-time seizure]]
*[[Eclampsia]]
*[[Febrile seizure]]
*[[Ethanol withdrawal]]


==References==
==References==

Latest revision as of 09:23, 22 March 2026

Background

  • Continuous seizure activity lasting >5 minutes, or ≥2 seizures without return to baseline[1]
  • Time-sensitive emergency — mortality increases with duration of seizure
  • 30-day mortality: 20% overall; higher in elderly and those with anoxic injury
  • Refractory SE: seizures persisting despite two appropriate first-line agents
  • Super-refractory SE: seizures persisting >24 hours despite anesthetic agents

Etiology

Clinical Features

  • Generalized convulsive SE: continuous tonic-clonic activity, most readily recognized
  • Non-convulsive SE: subtle or no motor manifestations; persistent altered mental status
    • Must maintain high suspicion in patients who remain altered after apparent seizure cessation
  • Complications: rhabdomyolysis, hyperthermia, lactic acidosis, aspiration, neuronal injury

Differential Diagnosis

Seizure

Evaluation

  • Bedside glucose — immediately
  • Labs: BMP (Na, Ca, Mg, glucose), CBC, AED levels, lactate, VBG, LFTs, toxicology screen
  • CT head — once stabilized; evaluate for structural cause
  • Continuous EEG — if available; essential to diagnose non-convulsive SE
  • LP if infection suspected (after CT and when safe)
  • CK, urinalysis (myoglobinuria) if prolonged seizure

Management

Time 0-5 min: Stabilize

  • ABCs, supplemental O2, cardiac monitor, IV access
  • Glucose: check immediately; give D50W 50 mL IV (or D10W) if hypoglycemic
  • Thiamine 100 mg IV before glucose if malnourished or alcoholic
  • Position patient to prevent aspiration; suction as needed

Time 5-20 min: First-Line — Benzodiazepines

  • Lorazepam 0.1 mg/kg IV (max 4 mg/dose), may repeat x1 in 5 min[2]
  • If no IV access: Midazolam 10 mg IM (most effective prehospital per RAMPART trial)
  • Alternatives: Diazepam 0.2 mg/kg IV (max 10 mg), or diazepam 20 mg PR

Time 20-40 min: Second-Line — Anti-Epileptic Drug

  • Levetiracetam 60 mg/kg IV (max 4500 mg) over 15 min[3]
  • Fosphenytoin 20 mg PE/kg IV (max rate 150 mg PE/min)
  • Valproic acid 40 mg/kg IV (max 3000 mg) over 10 min
  • ESETT trial: all three equally effective (~50% success each)

Time >40 min: Refractory SE

  • Intubation and continuous infusion of anesthetic agent:
    • Midazolam 0.2 mg/kg IV bolus, then 0.1-2 mg/kg/hr
    • Propofol 2 mg/kg IV bolus, then 2-10 mg/kg/hr (monitor for propofol infusion syndrome)
    • Pentobarbital 5 mg/kg IV bolus, then 1-5 mg/kg/hr
  • Continuous EEG monitoring required
  • Target: burst-suppression for 24-48 hours

Special Situations

  • INH overdose: Pyridoxine (B6) gram-for-gram (empiric 5 g IV if dose unknown)
  • Eclampsia: Magnesium sulfate 4-6 g IV
  • Hyponatremia: Hypertonic saline (3%) 100 mL IV bolus

Disposition

  • ICU admission for all SE patients
  • Neurology consultation
  • Patients with rapidly terminated seizures who return to baseline may be managed on a monitored floor

See Also

References

  1. ↑ Trinka E, et al. A definition and classification of status epilepticus. Report of the ILAE Task Force. Epilepsia. 2015;56(10):1515-1523. PMID 26336950.
  2. ↑ Silbergleit R, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med. 2012;366(7):591-600. PMID 22335736.
  3. ↑ Kapur J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus (ESETT). N Engl J Med. 2019;381(22):2103-2113. PMID 31774955.
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