Status Epilepticus managment for the medical interns

Status epilepticus foe interns

1. Status Epilepticus: Emergency Management and Clinical Presentation A Guide for Medical Interns Prepared by: Dr. Alaa Qashlan , MSc. Internal Medicine, MRCP(UK) Institution: Ibrahim Obaidallah Hospital

2. Case History Case Overview: 45-year-old male, found unconscious, stiffening and shaking, foaming at the mouth. Medications Found: Phenytoin, Valproic Acid. Clinical Course: Stopped shaking upon arrival, but resumed shortly. Importance of early identification and management. Mortality Rate: 16-39% depending on promptness of treatment.

3. Introduction to Status Epilepticus Definition: Convulsive Status Epilepticus (CSE) is a seizure lasting >5 minutes. Importance: A medical emergency requiring immediate intervention. Learning Objectives: Recognize the clinical presentation of status epilepticus. Understand the initial management steps. Learn to differentiate between convulsive and non-convulsive types.

4. Convulsive Status Epilepticus (CSE) Key Features: Seizure Duration: >5 minutes. Tonic- Clonic Movements: Stiffening (tonic phase) followed by shaking ( clonic phase). Mental Status: Impaired (coma, confusion, lethargy). The patient will typically have their eyes open and be unresponsive to commands or sensory stimuli.

5. Non-Convulsive Status Epilepticus (NCSE) Definition: Seizure activity without prominent motor symptoms. Suspect non-convulsive status epilepticus in a patient with a previous diagnosis of epilepsy if : Prolonged confusion greater than 20 minutes , personality changes, or recent-onset psychosis. It can follows convulsive SE. Diagnosis Tip: Requires high suspicion and EEG confirmation. Practical Tip: Easily missed; refer to neurology early.

6. Differential Diagnosis: Non-Epileptic Seizures Key Mimics: Non-epileptic (dissociative) seizures often mimic SE. Distinguishing Features: Long (>5 minutes) duration of individual seizures Fluctuating course (waxing and waning) Asynchronous rhythmic movements Pelvic thrusting Side-to-side head/body movements during a convulsion Closed eyes Ictal crying Later recall of items during the seizure. Management: Avoid unnecessary anticonvulsants; specialist consultation needed.

7. Acute Causes of Status Epilepticus Common Causes: Hypoxia, stroke, trauma, tumor, metabolic abnormalities, alcohol intoxication/withdrawal, non-adherence to anticonvulsants , infection, Pregnancy >20 wks -> eclampsia History Taking: Previous epilepsy, medication changes, recent illness or injury, substance use ( e.g., cocaine, amphetamines). Whether any medication has already been given to terminate the seizure. Any symptoms preceding the seizure that may suggest its cause (e.g., hypoglycaemia, thiamine deficiency, meningitis) Clinical Pearl: Consider potential reversible causes during initial assessment.

8. Physical Examination in Status Epilepticus Convulsive SE: Airway and Breathing: Assess for cyanosis, airway obstruction. Cardiovascular: Pulse, blood pressure, signs of shock. Neurological: Glasgow Coma Scale (GCS), pupil size and reactivity. Mydriasis is a common finding in epileptic seizures. Pregnancy Consideration: Palpable uterus may indicate eclampsia. Non-Convulsive SE: Neurological assessment and referral to neurology.

9. Laboratory and Imaging Investigations Laboratory Tests: Emergency Bloods: Glucose, Urea, Creatinine, LFT, electrolytes, CBC, CRP, Coagulation profile, anticonvulsant levels. ABG: Assess for acidosis/alkalosis. Toxicology: If substance misuse/overdose suspected. Imaging: CT Head: Urgent if no previous epilepsy, head injury, or refractory SE. Other Tests: Chest X-ray, ECG, lumbar puncture if needed . Practical Tip: Don’t delay treatment while waiting for test results.

10. Initial Management Approach Stabilization (ABC Approach): Airway: Secure airway, position patient semi-prone to prevent aspiration. Use a nasopharyngeal airway Breathing: Administer high-concentration oxygen. Circulation: Start cardiac monitoring, assess vitals. Interventions: Thiamine for suspected alcohol abuse, Do this before or at the same time as glucose. Give glucose if hypoglycemic, treat acidosis. Give Anticonvulsant Therapy

11. Anticonvulsant Therapy First-Line: Intravenous Lorazepam (4 mg, repeat if necessary). Alternative Routes: Buccal midazolam, rectal diazepam if IV access unavailable. Give the second dose of benzodiazepine if the seizure does not stop within 5 to 10 minutes of the first dose. Second-Line: If seizures persist after two adequate doses benzodiazepines , then start 2 nd line therapy: Options: Phenytoin, Levetiracetam, Sodium Valproate. Dosing: Phenytoin 15-20 mg/kg IV, followed by maintenance. Practical Tip: Move quickly from first to second-line treatments to avoid progression to refractory SE.

12. Management of Refractory Status Epilepticus Definition: SE not responding to first- and second-line treatments. Management: Transfer to ICU for possible phenobarbital or general anesthesia. Consultation: Involve a neurologist or epilepsy specialist. Clinical Pearl: Early involvement of ICU can be life-saving.

13. Summary and Key Takeaways Prompt Action: Early recognition and intervention in SE are crucial. Stepwise Management: Use a structured approach—ABC, followed by appropriate anticonvulsant therapy. Continuous Monitoring: Ongoing assessment and adjustment of treatment are key. Final Note: Always consider underlying causes and work closely with specialists.

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