Status epilepticus

Definition

Generalised tonic-clonic seizures lasting over 30 minutes or successive, discrete convulsions without recovery of consciousness.

Epidemiology

10-60 per 100 000 person/years. Higher incidence in the poor and recurs in about a third of patients.

Pathophysiology

You have epilepsy and then have fits. These ones last a long time and are very bad.

Risk Factors

• Having epilepsy
• <5 years old or elderly
• Genetic predisposition
• Mental handicap
• Structural brain pathology
• Preciptants
  • Drug withdrawal
  • Illness
  • Metabolic disturbance
  • Stroke
  • Alcohol intoxication or withdrawal

Clinical Features

Essentially, take a look at generalised tonic-clonic seizure for more detail but it's basically: a tonic phase - everything goes rigid; and a clonic phase rhythmical shaking.

Investigations

• Pulse oximetry
• Blood gas - check for acidosis
• Blood glucose - abnormal blood sugar can cause seizure
• U+Es - any electrolyte abnormality can cause seizure
• FBC
• ECG
• Clotting
• Anti-epileptic drug levels

5ml of blood and 50ml of urine for later sampling. Of the patients, not yours or some random persons. That'd be weird.

Management

Protective measures

Ensure head is protected; move them away from a dangerous area (like by stairs, swimming, near an angry lion); if possible, remove false teeth and don't get your fingers bitten off, remove constricting neck-wear (particularly important for those engaged in heavy bondage); call an ambulance

Doctor stuff

• ABC:
  • Secure airway with a Guedel or nasopharyngeal tube if possible
  • Give O₂
  • Monitor cardiorespiratory function and assess blood pressure
• Establish iv access - take bloods
• Drugs

1. Lorazepam - 4mg/2min iv. Watch out for respiratory arrest and have resus kit ready. (Alternative is diazepam 10mg/2min iv. This can be repeated 5mg/min until seizures stop or 20mg given.) Rectal diazepam if iv access cannot be gained and buccal midazolam (10mg[1ml] adults; 0.5ml 1-4 year olds; 0.25ml 6-12mo.) is a final option.
2. Phenytoin infusion 15mg/kg iv </=50mg/min (don't mix with diazepam). Monitor BP and ECG. Don't give in bradycardia or heart block.

• If fits don't stop - diazepam infusion 100mg in 500ml of 5% dextrose, 40ml/h (3mg/kg/24h). Monitor closely, check not pseudoseziure.

Further management

60-90 minutes after seizure, give them general anaesthesia and admit them to ITU. Then start oral anticonvulsants.