Approach to Seizure and Status Epilepticus

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Status epilepticus is a single seizure ≥5 minutes in length or two or more seizures without recovery  of  consciousness  between  seizures. Status  epilepticus  is  a  neurologic  emergency,  and  treatment  should be initiated in all patients with continuous seizure activity lasting more than 5 minutes.  

Clinical presentations 

  • Abrupt onset seizures
  • Altered mental status
  • Postictal drowsiness
  • Tongue biting

Differential diagnoses 

Epilepsy,  meningitis,  encephalitis,  malaria,  space  occupying  lesion,  alcohol  withdrawal,  isoniazid  toxicity,   intracranial hemorrhage, metabolic abnormalities - hyponatremia, eclampsia, acute  hydrocephalus. 

Investigations: 

Blood  Glucose,  Electrolytes:  (Sodium,  Potassium,  Chloride,  Magnesium  and  Calcium),  ECG,  Bedside  ultrasound,  Blood  gases,  Malaria  Test,  Serum  creatinine  and  urea,  Lactate  levels,  Pregnancy test (females), Toxicology screening and/orCT Head 

Non-pharmacological management 

  • Protect  patient  from  injury  (If  possible  place  in  left  lateral  position  to  reduce  aspiration risks), Don’t place tongue depressor
  • Perform both primary and secondary assessment and provide necessary interventions
  • Give Oxygen if needed
  • Do bedside random blood sugar test
  • Establish IV access for administration of anticonvulsants, if unable use the rectal route
  • Connect the patient to the cardiac monitor to obtain vital signs

Pharmacological management 
I. Active seizure 0-5minutes

Supportive care: 

IV access, monitors, maintain airway, oxygen therapy. Check point-of-care glucose and provide: 

A: dextrose 5%(IV); if glucose is ≤ 3.5mmol/L 

AND 

A:  diazepam  (IV)  0.15-0.2mg/kg.  Maximum  10mg  (Rectal  dose:  0.2-0.5mg/kg)  repeat every 5 minutes up to 3 doses 

OR 

D: midazolam (IV): 0.1mg/kg repeat every 5 minutes up to 3 doses 

II. Established Status Epilepticus 5-10 min

B:  phenobarbitone  (IV):    Adults  20mg/kg  slowly  (max  50mg/min);  Paediatrics  20mg/kg slowly (max 30mg/min) 

OR 

C:  phenytoin  (IV)  Adults  20mg/kg  slowly  (max  50mg/min);  Paediatrics  20mg/kg  slowly (max 30mg/min) 

Consider INTUBATION if patient still seizing 

C:  thiopental  (IV):    Adult  3-6mg/kg  loading  dose  then  25-100mg  infusion  as  needed; Paediatrics 2-5mg/kg loading dose  

OR 

D:  propofol  (IV):  Adults  2mg/kg  loading  dose  then  2-10mg/kg/hour;  Paediatrics  3mg/kg loading dose, then 7.5-18mg/kg/hr  

OR 

D:  midazolam  (IV):  Adult  0.2mg/kg  loading  dose  then  0.1-0.2mg/kg/hour;  Paediatrics 0.1mg/kg then infusion 0.06 – 0.4mg/kg/hour 

Disposition: Intensive  care  unit  admission  or  refer  to  the  higher  health  facility  with  ICU/HDU  capacity