Status Epilepticus- a recap of management!

Recap of the Management for Status Epilepticus (SE)...

First off, recall why Status is an Emergency: 

1) Risk of Systemic Complications: aspiration pneumonia, respiratory distress, hyperthermia, hyperkalemia, lactic acidosis, AKI, hypoxic brain injury, neurogenic pulmonary edema, etc 

2) Potential Neurological Sequelae: some studies in baboons who were intubated, paralyzed and in status epilepticus, demonstrated cerebral changes suggestive of ischemia in the grey matter. This may suggest that prolonged epileptic activity may cause neuronal injury independent of the systemic complications that arise...

(Journal Abstract: http://archneur.jamanetwork.com/article.aspx?articleid=572289)

3) Duration of Seizures: longer duration may result in more resistance with respect to treatment...

Some retrospective studies have demonstrated that patients that respond to first-line therapy often had a shorter total duration of seizure activity prior to successful treatment that those who did not respond to initial first-line measures. This may suggest that the longer the duration of SE, the more refractory a patient may become to treatment.

(Journal Abstract: http://www.neurology.org/content/43/3_Part_1/483.abstract)

Management: assess ABCs, IV access, monitored setting, neuroVS and regular VS; order stat blood work while managing (i.e. Stat Accucheck blood glucose, electrolytes, Ca, Mg, PO4, Albumin, AST, ALT, GGT, ALP, INR, Bilirubin, CK, TSH, toxicology screen, EtOH serum level, anti-epileptic drug level).

Other considerations (things to order once more stable): 12-lead ECG, troponin/Ck, CT head (*may consider MRI to better delineate soft tissue structures, depending on CT head results), EEG, +/- Lumbar Puncture (if consideration of CNS infection, such as meningitis)

ACUTE SEIZURE CONTROL: ABCs, IV access

1^st line- Benzodiazepine: lorazepam 1mg -2mg IV/SL PRN, up to total of 0.1 mg/kg. Can also be given IM; Diazepam 0.1-0.3 mg/kg IV. Diazepam can also be given rectally (10 mg PR x1, if no IV access)!!!

·       MOA: increase [Cl]- conductance in CNS GABA RC—decreasing neuronal excitability

2^nd line-Phenytoin (Dilantin) 15-20 mg/kg IV loading dose (maximum rate of 50 mg/minute for the infusion); maintainence 100 mg IV q8h

·       Benefit: efficacy in preventing recurrence of SE for extended period

·       NOTE: Modify infusion for hypotension, arrhythmia, pain/injury at infusion sites. The patient should be in a monitored setting and on a cardiac monitor!

·        DRAWBACK: must be dissolved in propylene glycol to remain soluble in IV form; Propylene glycol is the cause of most AV block and hypotension. It is also thought to cause “purple glove syndrome” resulting in pain, swelling and discoloration of the limb at the infusion site

·       MOA: stabilizes the neuronal membranes; decreases seizure activity by increasing efflux or decreasing influx of Na+ across the cell membrane in the motor cortex during generation of nerve impulses; shortens the action potential in the heart

Fosphenytoin= a pro-drug to phenytoin that is highly water soluble, thus, unlikely to precipitate during IV administration and reduced rate of local irritation

·       -Express dose in phenytoin sodium equivalents (PE)

o    i.e. 15-20 mg PE/kg at 100 mg PE/min

3rd line- Barbituates: similar to benzos, with a MOA of binding to GABA A RC, amplifying action of GABA by extending GABA-mediated Cl channel openingà increase Cl- outflow across membraneàneuronal hyperpolarization

Phenobarbital: administration is slow, causes prolonged sedation

·       Higher risk of hypoventilation and hypotension

·       Dose: 10- 20 mg/kg loading dose, infuse at 50 mg/min *(slower in elderly), may repeat dose at q20 minute intervals as needed (to maximum 30 mg/kg)

·       Monitor cardio-resp status! May need an ETT…

4th line- Propofol: a general anaesthetic 

·       Risk: Metabolic acidosis, renal failure, rhabdomyolysis, cardiac dysfunction

·       MOA: short acting, lipophilic IV GA, that causes global CNS depression through agonism of GABA A RC and perhaps reduced glutametergic activity via NMDA RC blockade

·       Dose: 1-2 mg/kg bolus IV, then 2-10 mg/kg/h

·       These patients typically have a definitive airway and are in the ICU!