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

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.