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Proposed Algorithm for Convulsive Status Epilepticus (JPG)
- Definition
- Seizure lasting > 30 minutes or repeated seizures with no return to baseline between seizures
- Also defined as any seizure > 5 minutes
- Refractory status epilepticus – seizures lasting > 2 hours or > 2 seizures/hour with no return baseline despite AED administration
- Nonconvulsive status epilepticus –high morbidity and mortality
- Causes: AED non-compliance, glucose abnormalities, metabolic disturbances, sepsis, uremia, CNS infection or tumor, CVA, ETOH withdrawal, cocaine, drug toxicities (PCN, cephalosporins, ciprofloxacin, tacrolimus, cyclosporine, theophylline)
Management of Status Epilepticus
- ABC
- assess need for airway protection
- monitor, vital signs, and IV access
- Check glucose!!!
- Other labs: CBC + CMP + Utox + AED levels + ABG
- Consider continuous EEG (at least 24 hours for 80% sensitivity).
Initial Therapy
lorazepam 2 mg IV, repeat 2-4 mg IV q 1-2 minutes to max 0.1 mg/kg
OR
midalozam 0.2 mg/kg IM, up to a maximum 10 mg
+
levetiracetam 2 g IV bolus
OR
fosphenytoin IV load 20 mg/kg with gtt (150 mg/min IV)
- Additional agents if seizures continue
- Phenobarbital 5 mg/kg IV to max of 20 mg/kg q 15 minutes
- Valproate 20-40 mg/kg IV bolus over 10 minutes (consider if hx of generalized epilepsy)
- Lacosamide 100-200mg IV BID
- Refractory Status Epilepticus (RSE)
- Start continuous of anesthetic infusion
midalozam 0.2 mg/kg load, starting rate 2 mg/min
OR
propofol 1-2 mg/kg load, start rate at 20 mcg/kg/min to max 200 mcg/kg/min
OR
pentobarbital 5-15 mg/kg load, 0.5-5 mg/kg/hr infusion
- Consider head CT and LP
- Monitor levels of AEDs
- Once controlled ► continue infusion for 24 hours and gradually wean infusion with continuous EEG. Start IV AED caution with phenobarbital withdrawal as it may induce seizures.