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Neurologist and neurointensivist Gracia Mui shows us the workup, initial management, and escalation of care for a case of refractory status epilepticus.
Takeaway lessons
- First-time unprovoked seizures usually need no further workup except screening for an underlying trigger, such as a tox screen, basic chemistries, and imaging as appropriate.
- Initial seizure therapy: wait around 5 minutes, then give 2–4 mg lorazepam. Repeat every minute or so until convulsions stop, up to 0.1 mg/kg total.
- Give an anti-epileptic concurrently: fosphenytoin or phenytoin (15–20 mg/kg), levetiracetam, or valproic acid (40 mg/kg, up to 3000 mg) are all acceptable. If using levetiracetam (Keppra), give a real dose of 60 mg/kg (max of 4.5 g).
- After loading with benzos and/or anti-epileptics, if convulsions stop and the patient remains unresponsive, consider the duration of the drug you used. If it’s wearing off (e.g. after about an hour for lorazepam) and they remain unresponsive, suspect non-convulsive status epilepticus.
- Any patient not waking up needs an EEG. If not available, they may need empiric deep sedation and intubation until EEG can prove the absence of seizures.
- If convulsions are absent, that’s good, as convulsive seizures are more harmful than non-convulsive, but not as good as obviating seizure activity on EEG.
- Other than the practical, there is no upper limit for benzodiazepine dosing.
- Once you’ve successfully achieved the desired EEG result (either burst suppression or simply the absence of seizure activity) using anesthetics, hold them for about a day, then lighten sedation to see if seizures recur. If so, re-deepen sedation (perhaps for twice as long), increase anti-epileptic agents, then try again.
- The patient in status should routinely be screened for underlying triggers, including brain imaging and LP (remember autoimmune causes such as NMDA encephalitis). But about half the time, even in severe refractory status, no underlying cause will be identified.
Resources
References
- Kapur J, Elm J, Chamberlain JM, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103–2113. doi:10.1056/NEJMoa1905795
[this episode was reposted on the website 4/27/2020 due to a database reversion after an unfortunate system breach —ed.]