Status Epilepticus: Emergency Treatment, Initial Investigation and Long-term Treatment

by Roy Strowd, MD

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    00:01 How about the treatment for status epilepticus? Let's walk through what we do emergently.

    00:06 And with our initial investigations and long-term treatment to stop this continuous seizure activity.

    00:12 We'll start with the first five minutes.

    00:14 This is the stabilization phase, and we do the ABCs.

    00:17 We focus on airway, breathing, circulation, and any disability or neurologic exam abnormalities.

    00:24 We need to make sure the patient has an open airway, That airway is clear of blood or sputum production or those things.

    00:31 We focus on breathing and often provide oxygen supplementation, and don't tend to have circulatory arrest unless there's another potential cause of the status.

    00:40 But those ABCs are important for any patient who's presenting with a life threatening emergency.

    00:47 The second piece is to look at the time.

    00:49 And time the seizure from its onset and monitor vital signs rigorously during that first few minutes of the seizure.

    00:56 The first three minutes feel like three hours.

    00:59 Though most seizures 90% to 95% of seizures will resolve spontaneously within the first three minutes.

    01:06 We assess oxygenation.

    01:08 Give oxygen via nasal canula, facemask, and may consider intubation if there is respiratory dysfunction or concern for respiratory arrest, or assistance is needed.

    01:18 we initiate EKG or ECG monitoring for all these patients, either by EMS in the field, or in route, in an ambulance, or in the emergency department.

    01:27 And then we typically think about collecting some early tests that can help to intervene for patients who may have an exacerbation that's causing this continuous seizure activity.

    01:37 Hypoglycemia, even hyperglycemia can cause seizures, and so we collect a fingerstick, blood glucose, and intervene.

    01:44 The intervention is different for children by age and in adults, we think about both D50.

    01:49 To to rescue hypoglycemia, as well as intravenous thiamine.

    01:55 And then the last step during the stabilization phase is to attempt IV access, collect electrolytes for blood testing, hematology, or toxicology screening.

    02:06 And if appropriate, check anticonvulsant levels for patients who may be on anti-epileptic medicines and have a diagnosis of epilepsy.

    02:14 So that stabilization phase is critical.

    02:16 We think about it in the first zero to five minutes, but maybe in the first zero to two, or three minutes for patients who suffer a new onset of seizure in a hospital setting.

    02:27 If the seizure does continue, we consider the initial therapy phase if the seizure does not continue, then the patient proceeds to symptomatic medical management and care.

    02:37 During this initial therapy phase, there are a number of interventions that are done to stop the seizure from occurring.

    02:44 Benzodiazepines are the initial therapy of choice for aborting a seizure, and for stopping status epilepticus.

    02:52 We typically choose one of several agents including intramuscular midazepam, intravenous lorazepam, and intravenous diazepam.

    03:02 These are equivalent medicines and sometimes it depends on the availability of those.

    03:06 We want to get them started and get them started quickly to abort that seizure.

    03:11 If none of these agents are available, we can consider intravenous phenobarb, as well as rectal diazepam, or intranasal midazolam.

    03:19 And I mentioned those because that can be used by patients or caregivers at home.

    03:23 In a chronic epileptic who has breakthrough seizures, and we really want to prevent multiple recurrent seizures.

    03:28 Rectal administration of diazepam, or intranasal midazolam can be performed at home.

    03:35 If the seizure continues, we repeat the intravenous, intramuscular, intranasal benzodiazepine up to three times spaced out about every three to five minutes.

    03:46 If the seizure continues, we move into the second line therapy phase.

    03:50 If the seizure does not continue, and abates after abortion with the benzodiazepine, we work on symptomatic medical management.

    03:58 And in many of those patients, we continue on to second line therapy to stop the seizure from recurring after it has initially been aborted.

    04:10 During the second line therapy phase, we think about a number of medicines, anti-epileptics, and we'll talk about three that are used to stop the seizure.

    04:18 These are anticonvulsant medications.

    04:21 And we tend to think of one of three medicines.

    04:24 Intravenous fosphenytoin, intravenous valproic acid and intravenous levetiracetam.

    04:31 These are important medicines to remember.

    04:33 These are the definitive treatments for status epilepticus.

    04:37 And their doses are sometimes tested.

    04:39 And are things we need to know in this emergent setting to manage these patients.

    04:43 Fosphenytoin is given at a dose of 20 mg per kg.

    04:47 Valproic acid is given an a dose of 40 mg per kg, and levetiracetam has given it a dose of 60 mg per kg.

    04:54 And we'll talk about those a little later in the lecture as well.

    04:57 If none of these are available, we can consider intravenous phenobarbital.

    05:01 Historically, this was the medicine used as the first choice for status epilepticus.

    05:05 But it has been replaced by these newer agents.

    05:09 So again, then we reevaluate the patient after administration of that agent.

    05:13 And if the seizure continues, we move into the third phase of treatment, and if not, we move to symptomatic management of the patient, at that time.

    05:21 There's no clear evidence or guide about what to do in this third phase of treatment.

    05:26 This is for seizures that continue after that initial definitive treatment.

    05:31 Typically, we would consider a second line therapy.

    05:34 So a fosphenytoin was selected, initially.

    05:36 We'd move to valproic acid, or levetiracetam.

    05:39 If levetiracetam was administered initially, we'd moved to fosphenytoin or valproic acid.

    05:45 And that's the initial management of status epilepticus.

    About the Lecture

    The lecture Status Epilepticus: Emergency Treatment, Initial Investigation and Long-term Treatment by Roy Strowd, MD is from the course Seizures and Epilepsy.

    Included Quiz Questions

    1. Assess airway, breathing, and circulation
    2. Fingerstick for blood glucose
    3. Initiating an ECG
    4. Make a note of the time
    5. Administer medication
    1. Administer IV lorazepam if the seizure continues.
    2. Medications should be administered even if the seizure has resolved.
    3. Administer IV phenobarbital if the seizure continues.
    4. Administer rectal diazepam if the seizure continues.
    5. Administer intranasal midazolam if the seizure continues.
    1. 20 mg/kg IV fosphenytoin
    2. 50 mg/kg IV phenobarbital
    3. 100 mg/kg IV levetiracetam
    4. 10 mg/kg IV valproate
    5. 0.5 mg/kg intranasal midazolam

    Author of lecture Status Epilepticus: Emergency Treatment, Initial Investigation and Long-term Treatment

     Roy Strowd, MD

    Roy Strowd, MD

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