Status epilepticus is when a seizure continues for longer than five minutes or when multiple shorter seizures occur with incomplete recovery between them
Refractory status epilepticus is defined as persistent seizures despite two adequate doses of intravenous (IV) anti-convulsant agents
Causes of seizures
Known epilepsy
Drug withdrawal, non-compliance or therapy alteration
Inter-current illness
Metabolic derangements
Seizure threshold-lowering drugs
No history of epilepsy
Drug overdose
E.g. amphetamines, tricyclic antidepressants (TCAs)
Drug withdrawal
E.g. alcohol
Central nervous system (CNS) injury
Traumatic brain injury (TBI)
Acute stroke
Subarachnoid haemorrhage (SAH)
Cerebral hypoxia
CNS infection
Meningitis
Encephalitis
Cerebral abscess
Metabolic derangements
Clinical features of seizures
Witnessed or unwitnessed
Collateral history if possible
Prodrome
Loss of consciousness
Convulsions
Tongue biting
Urinary incontinence
Post-ictal period
Injuries
Initial investigation of a seizure
Glucose
Venous blood gas (VBG)
Full blood count
Urea & electrolytes
Magnesium
Calcium
Further investigation of seizures or status epilepticus
Guided by the likely cause but may include
CT head
Bloods cultures
Toxicology screen
Lumbar puncture (LP)
12 lead electrocardiogram (ECG)
Look specifically for prolonged PR, QRS and QT interval
Initial management of seizures
On recognition of a tonic-clonic seizure, instruct nursing staff to prepare lorazepam 4 mg IV in 4 ml of 0.9% saline (1mg/ml) with a 10 ml 0.9% saline flush and start the clock
Remove any objects in the immediate environment on which the patient might injure themselves
Roll the patient on to their side whilst supporting the airway with a jaw thrust
Insert a nasopharyngel airway and provide high-flow oxygen
Do not use an oropharyngeal airway (OPA). Due to trismus, insertion is unlikely to be successful and may result in the OPA shattering within the patient’s mouth
Attach monitoring
Pulse oximetry
Non-invasive blood pressure
Three-lead cardiac monitoring
Check capillary blood glucose
Treat hypoglycaemia if present; options are:
Dextrose 50% 50 ml IV
Dextrose 20% 100 ml IV
Dextrose 10% 250 ml IV
Glucogel/Hypostop if IV access still not available
Obtain intravenous (IV) access if not already secured and take bloods
Correct any electrolyte abnormalities
Give Pabrinex 2 pairs IV if there is any history of alcohol misuse or poor nutritional status
Within five minutes: Give the first dose of benzodiazepine unless given already (e.g. pre-hospital) in which case, proceed to the next step
If IV access available, give up to 4 mg of lorazepam IV in 1 mg boluses titrated to effect
The goal is to give the patient just enough lorazepam but no more, thereby terminating the seizure but not leaving them excessively obtunded
If IV access is unavailable, give diazepam 10 mg per rectum (PR) or midazolam 10 mg buccal and keep trying to obtain IV access
Interosseous (IO) access may be needed if IV cannot be obtained
Consider the next steps. Is this a patient who may need intubation?
If so consider calling the anaesthetist now.
Ten minutes after first benzodiazepine: give second dose of benzodiazepine unless given already (e.g. pre-hospital) in which case, proceed to the next step:
If IV access available, give up to 4 mg of lorazepam IV in 1 mg boluses titrated to effect
If IV access is unavailable, give diazepam 10 mg per rectum (PR) or midazolam 10 mg buccal and keep trying to obtain IV access
Ask the nursing staff to prepare phenytoin 18 mg/kg IV or phenobarbital 20 mg/kg IV if patient normally takes oral phenytoin
Ten minutes after second benzodiazepine
Request senior help if not already present and give phenytoin or phenobarbital as appropriate
Phenytoin 18 mg/kg IV or phenobarbital 20 mg/kg IV if patient normally takes oral phenytoin
Contact the on-call anaesthetist and inform the intensive care unit (ICU)
15 minutes after third agent (i.e. after maximum of 40 minutes since status began)
Give a rapid sequence induction (RSI) with thiopental and transfer to ICU
Further management of seizures
Correct any electrolyte abnormality
CT head if first presentation, not done previously, clinical features suggests new neurology, or if precipitated by TBI
Bloods cultures
Toxicology screen
Lumbar puncture (LP)
12 lead ECG
Look specifically for prolonged PR, QRS and QT interval
Electroencephalopgram (EEG)
If first presentation, referral to first fit clinic
