Status epilepticus refers to continuous seizure activity, which has failed to self-terminate.
Status epilepticus (SE) or ‘status’ is medical emergency. More than 15% of patients with epilepsy will have at least one episode of SE, which can be life-threatening. It is traditionally defined by the duration of continuous seizure activity and effect on consciousness.
The majority of seizures will spontaneously terminate within 3 minutes and do not require emergency treatment. However, those with sustained seizures are at risk of long-term neurological damage. The highest risk is with generalised tonic-clonic seizures.
In clinical practice, there is urgency to treat SE to prevent irreversible neurological damage. This means the traditional definitions may not be practical.
Instead, patients should be treated as SE if they have the following:
Status epilepticus can be divided into convulsive and non-convulsive status.
Convulsive SE is used to describe the typical, sustained generalised tonic-clonic seizure, which presents with generalised muscle stiffening and rhythmic muscle jerking. Other types may include myoclonic status, tonic status and focal motor status.
A background of epilepsy is single strongest risk factor for generalised convulsive SE
Non-convulsive SE is used to describe a long or repeated absence or focal impaired awareness seizure. These patients do not have classical convulsive movements that make it easy to recognise. Instead, it usually requires a high degree of suspicion and evidence of epileptiform activity on electroencephalogram (EEG).
Clinical features may include altered mental status, subtle twitching or myoclonic jerks, unusual behaviour or speech disturbance.
In the pre-hospital setting, patients with known epilepsy may develop seizures that self-terminate and do not require medical attention.
The need for medical attention depends on the underlying illness, type of epilepsy, complications from seizure or risk of SE.
Basic seizure first aid:
*NOTE: rescue medications may be prescribed for patients known to have recurrent seizures. They can include buccal midazolam or rectal diazepam.
Any seizure in hospital should be treated as a medical emergency.
In a hospital setting, it may be difficult to determine whether a seizure will spontaneously terminate or require treatment for SE. This is especially true if a seizure is witnessed or there is no delay in assessment (< 5 minutes). Therefore, any seizure developing in hospital should be treated as a medical emergency and managed with a structured ABCDE approach.
We can divide the assessment and management of seizures into different stages based on seizure duration.
*NOTE: bloods can be taken at the same time for a venous blood count, full blood count, urea & electrolytes, coagulation, glucose, bone profile, magnesium, liver function tests, anti-convulsant drug levels, cultures (if appropriate)
Emergency anti-epileptic drugs are critical to seizure control.
Benzodiazepines are the cornerstone of initial seizure treatment. It is essential to check whether any pre-hospital benzodiazepines have already been administered.
A further single dose of benzodiazepine can be administered within 10-20 minutes if seizures have not been controlled. Ensure usual AEDs have been administered.
If the seizure has not been controlled by two doses of benzodiazepine, patients require loading (i.e. IV infusion) of a 2nd line AED.
At present, phenytoin is the only licensed agent, but other AEDs are being increasingly used. Always check local hospital SE guidelines.
If a patient is refractory to previous medications, they should be referred to ITU for general anaesthesia with intubation and ventilation. Anaesthesia should be continued for a minimum of 12-24 hours and guided by EEG monitoring.
Patients with non-convulsive status require discussion with neurology for specialist advice on management.
All patients with SE should be discussed with the specialist neurology team and ideally reviewed within 24 hours.
Patients presenting with their first seizure will require consideration of maintenance AEDs depending on the suspected underlying cause. This should involve formal discussion with neurology.
Those who already have a diagnosis of epilepsy require optimisation of their current medication. Follow-up and routine review can be arranged as necessary on discharge.
SE can be fatal or associated with long-term neurological morbidity.
Major acute complications include:
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