status epilepticus ( Neurology) ........

Status Epilepticus from neurology

1. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine
Management of Management of
Status EpilepticusStatus Epilepticus
Dr. Bandar Al-Jafen, MDDr. Bandar Al-Jafen, MD
Consultant Neurologist and Consultant Neurologist and
EpileptologistEpileptologist

2. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine

Seizures are dramatic and frightening for all who Seizures are dramatic and frightening for all who
witness the event witness the event –– and tend to induce panic, rather and tend to induce panic, rather
than rational thought, even on a neurology service.than rational thought, even on a neurology service.

Clinical seizures are caused by an excessive, Clinical seizures are caused by an excessive,
synchronous, abnormal discharge of cortical neurons synchronous, abnormal discharge of cortical neurons
that produces a sudden change in neurologic function.that produces a sudden change in neurologic function.

Seizures may be Seizures may be focalfocal, involving a single brain region , involving a single brain region
and causing limited dysfunction, or they may be and causing limited dysfunction, or they may be
generalizedgeneralized, involving the whole brain and producing loss , involving the whole brain and producing loss
of consciousness and convulsions.of consciousness and convulsions.
22

3. Status EpilepticusStatus Epilepticus
Status epilepticus (SE) is a serious, potentially lifeStatus epilepticus (SE) is a serious, potentially life--
threateningthreatening..
((SESE ) )defined as recurrent convulsions that last for defined as recurrent convulsions that last for
more than 30 minutes and are interrupted by more than 30 minutes and are interrupted by
only brief periods of partial reliefonly brief periods of partial relief..
Any type of seizure can lead to SE, the most serious form Any type of seizure can lead to SE, the most serious form
of status epilepticus is the generalized tonic-clonic typeof status epilepticus is the generalized tonic-clonic type..

4. SESE
Gastaut defined SE as "Gastaut defined SE as "an epileptic seizure that is so an epileptic seizure that is so
frequently repeated or so prolonged as to create a fixed frequently repeated or so prolonged as to create a fixed
and lasting epileptic conditionand lasting epileptic condition ..
” ”No precise clinical duration was specifiedNo precise clinical duration was specified..
The International League Against Epilepsy specified "a The International League Against Epilepsy specified "a
single epileptic seizure of >30-min duration or a series of single epileptic seizure of >30-min duration or a series of
epileptic seizures during which function is not regained epileptic seizures during which function is not regained
between ictal events in a between ictal events in a 30-minute period30-minute period””
1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine

5. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine

Your patient have seizure: What to do ?Your patient have seizure: What to do ?

QuestionsQuestions
1.1.Is the patient still seizing? If yes, how long has it Is the patient still seizing? If yes, how long has it
been going on?been going on?
2.2.What is the patientWhat is the patient’’s level of consciousness?s level of consciousness?
3.3.Is this the first known seizure for this patient?Is this the first known seizure for this patient?
4.4.Is the patient on anticonvulsant medication?Is the patient on anticonvulsant medication?
5.5.Is the patient diabetic?Is the patient diabetic?
55

6. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine 66
On the WayOn the Way

What is the differential diagnosis of seizures?What is the differential diagnosis of seizures?
V (vascularV (vascular):): Intracranial hemorrhage, acute or chronic ischemic Intracranial hemorrhage, acute or chronic ischemic
infarction, subarachnoid hemorrhage, arteriovenous infarction, subarachnoid hemorrhage, arteriovenous
malformation, venous sinus thrombosis.malformation, venous sinus thrombosis.
I (infectious):I (infectious): meningitis or abscess .meningitis or abscess .
T (traumatic):T (traumatic): new head injury old head injury with subdural new head injury old head injury with subdural
hematomahematoma
A (autoimmune):A (autoimmune): systemic lupus erythematosus, (CNS) vasculitis. systemic lupus erythematosus, (CNS) vasculitis.
M (metabolic/toxic):M (metabolic/toxic): hypo- or hypernatremia, hypo- or hypo- or hypernatremia, hypo- or
hypercalcemia, hypomagnesemia, hyper-thyroidism, uremia, hypercalcemia, hypomagnesemia, hyper-thyroidism, uremia,
hyperammonemia, ethanol (EtOH) toxicity or EtOH hyperammonemia, ethanol (EtOH) toxicity or EtOH
withdrawal, drugs cocaine, phenycyclidine, and amphetamineswithdrawal, drugs cocaine, phenycyclidine, and amphetamines
I (idiopathic/iatrogenic):I (idiopathic/iatrogenic): idiopathic epilepsy or medications idiopathic epilepsy or medications
N (neoplastic)N (neoplastic)
S (structural)S (structural)

7. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine 77

8. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine 88
MAJOR THREAT TO LIFEMAJOR THREAT TO LIFE

Aspiration of gastric contents if the airway is not Aspiration of gastric contents if the airway is not
protected protected

Head injuryHead injury

Lactic acidosis,Lactic acidosis, hypoxia, hypoxia, hyperthermiahyperthermia, ,
rhabdomyolysis, rhabdomyolysis, cerebral edemacerebral edema, or hypotension from , or hypotension from
a prolonged seizure. These conditions may produce a prolonged seizure. These conditions may produce
permanent brain injury.permanent brain injury.

The patient should be positioned in the The patient should be positioned in the lateral decubituslateral decubitus
positionposition to prevent aspiration of gastric contents. to prevent aspiration of gastric contents.

9. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine 99
Management on BedsideManagement on Bedside

Treatment of an Ongoing SeizureTreatment of an Ongoing Seizure
1.1.Keep calm.Keep calm.
1.1.It is likely that others in the room are reacting with fear or It is likely that others in the room are reacting with fear or
panic.panic.
2.2. Ask family members to leave the room.Ask family members to leave the room.
3.3. Tell them you will speak with them as soon as the Tell them you will speak with them as soon as the
situation is evaluated and under control.situation is evaluated and under control.
2.2.Have one or two people maintain the patient in a lateral Have one or two people maintain the patient in a lateral
decubitus position.decubitus position.
3.3.Administer oxygen by nasal cannula or face mask.Administer oxygen by nasal cannula or face mask.
4.4.Watch and wait for 2 minutes.Watch and wait for 2 minutes. A majority of seizures will A majority of seizures will
stop spontaneously within a short time. stop spontaneously within a short time.

10. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine 1010

Check the Check the finger stick glucosefinger stick glucose level. level.

Make sure there are Make sure there are two IV setups availabletwo IV setups available,, at least one with at least one with
0.9% normal saline (NS). If the patient has no IV access, start 0.9% normal saline (NS). If the patient has no IV access, start
an IV line. IV insertion and blood drawing will be much easier.an IV line. IV insertion and blood drawing will be much easier.

Draw Diazepam 5mg IV slowly.Draw Diazepam 5mg IV slowly.
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Elicit any further historyElicit any further history not obtained initially. not obtained initially.
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Is this a first-ever seizure? Is the patient on anticonvulsants? Is this a first-ever seizure? Is the patient on anticonvulsants?
What is the patientWhat is the patient’’s admitting diagnosis? Is the patient s admitting diagnosis? Is the patient
diabetic? Has the patient been febrile in the last 24 hours? Ask diabetic? Has the patient been febrile in the last 24 hours? Ask
for the chart to be brought to the bedside.for the chart to be brought to the bedside.

Observe the seizure type.Observe the seizure type.

11. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine 1111

Order the following Order the following blood tests:blood tests: (CBC), electrolytes, glucose, magnesium (CBC), electrolytes, glucose, magnesium
(Mg), calcium (Ca), EtOH level, toxicology screen, and anticonvulsant level (Mg), calcium (Ca), EtOH level, toxicology screen, and anticonvulsant level
(if applicable).(if applicable).
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If the patient is hypoglycemic, give If the patient is hypoglycemic, give glucose (50 ml of D50W).glucose (50 ml of D50W). If there is If there is
any history or suspicion of alcoholism, administer any history or suspicion of alcoholism, administer thiamine 100 mg by thiamine 100 mg by
slow, direct injection over 3 to 5 minutes.slow, direct injection over 3 to 5 minutes. If hypoglycemia is the cause If hypoglycemia is the cause
of the seizure, the seizure should stop, and the patient should wake up of the seizure, the seizure should stop, and the patient should wake up
soon after the glucose administration.soon after the glucose administration.
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An Ambu bag with face mask should be at the bedside because An Ambu bag with face mask should be at the bedside because
benzodiazepines can cause respiratory depression. benzodiazepines can cause respiratory depression.

12. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine 1212
Treatment of Status EpilepticsTreatment of Status Epileptics

If the seizure has not stopped with a full dose of a If the seizure has not stopped with a full dose of a
benzodiazepine, administer benzodiazepine, administer phenytoinphenytoin 15 to 20 mg/kg as a 15 to 20 mg/kg as a
slow IV infusion.slow IV infusion. (This loading dose corresponds to (This loading dose corresponds to
approximately 1500 mg in a 70-kg patient.) The rate of approximately 1500 mg in a 70-kg patient.) The rate of
administration should not exceed 50 mg/min because administration should not exceed 50 mg/min because
phenytoin can cause cardiac arrhythmias, prolongation of the phenytoin can cause cardiac arrhythmias, prolongation of the
QT interval, and hypotension. QT interval, and hypotension.

(ECG)(ECG) should be monitored continuously, and the blood should be monitored continuously, and the blood
pressure should be checked during the infusion. If IV access is pressure should be checked during the infusion. If IV access is
unavailable, fosphenytoin can also be given IM.unavailable, fosphenytoin can also be given IM.

Approximately 70% of prolonged seizures will be brought Approximately 70% of prolonged seizures will be brought
under control, but under control, but if the seizure lasts longer than 30 if the seizure lasts longer than 30
minutes,minutes, transfer the patient to an intensive care unit transfer the patient to an intensive care unit
(ICU)(ICU) for probable intubation. for probable intubation.

13. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine

14. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine 1414

Once the patient is in the ICU,Once the patient is in the ICU, if the patient is if the patient is
continuing to seize despite a full phenytoin load, the continuing to seize despite a full phenytoin load, the
next step is to administer barbiturates. next step is to administer barbiturates.
Phenobarbital should be infused loading dose of Phenobarbital should be infused loading dose of
15 to 20 mg/kg.15 to 20 mg/kg.

Alternatives to phenobarbital include Alternatives to phenobarbital include midazolam midazolam
(Versed) 0.2 mg/kg bolus, followed by IV (Versed) 0.2 mg/kg bolus, followed by IV
infusion of 0.1 to 2 mg/kg/hour, propofol 3 to 5 infusion of 0.1 to 2 mg/kg/hour, propofol 3 to 5
mg/kg loading dose.mg/kg loading dose.

General anesthesia with halothane and neuromuscular General anesthesia with halothane and neuromuscular
blockade has been used in some cases to avoid blockade has been used in some cases to avoid
rhabdomyolysis, but this eliminates the ability to rhabdomyolysis, but this eliminates the ability to
follow the neurologic examination. follow the neurologic examination.

15. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine

16. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine

17. EpidemiologyEpidemiology

18. EpidemiologyEpidemiology
1/31/3 cases are due to acute insults to the brain, including cases are due to acute insults to the brain, including
meningitis, encephalitis, head trauma, hypoxia, meningitis, encephalitis, head trauma, hypoxia,
hypoglycemia, drug intoxication orhypoglycemia, drug intoxication or
withdrawalwithdrawal
1/31/3 cases have a history of chronic epilepsy or febrile cases have a history of chronic epilepsy or febrile
convulsionsconvulsions
1/31/3 of cases of new-onset epilepsyof cases of new-onset epilepsy

19. CauseCause
0
5
10
15
20
25
30
35
The comprehensive evaluation and treatment of epilepsy,Steven C.Schachter,Donald L,Schomer

20. ComplicationComplication
Cardiac: HTN, tachycardia, arrhythmiaCardiac: HTN, tachycardia, arrhythmia
Pulmonary: apnea, hypoxia, respiratory failurePulmonary: apnea, hypoxia, respiratory failure
hyperthermiahyperthermia
Metabolic derangementMetabolic derangement
Cerebral: neuronal damageCerebral: neuronal damage
DeathDeath

21. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine

23. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine
Home MessagesHome Messages::
Seizure is a medical emergencySeizure is a medical emergency..
DonDon’’t panict panic..
Always keep the protocol in your mindAlways keep the protocol in your mind..
DonDon’’t hesitate to call the neurology team t hesitate to call the neurology team
immediately after you stabilized the Pt OR immediately after you stabilized the Pt OR
prolonged seizureprolonged seizure..
Keep in your mind that seizure is a symptom not Keep in your mind that seizure is a symptom not
a diagnosisa diagnosis. .

24. 1 March 2025
Dr. Bandar Al-Jafen - Neurology Unit -
Department of Medicine
Thank YouThank You