Status epilepticus

Status epilepticus is a life-threatening neurological condition and carries a high mortality and morbidity. Manage and investigate concurrently. Seek to achieve seizure control within the first 1 to 2 hours after the onset of symptoms as this will significantly affect the prognosis.

Take an Airway, Breathing, Circulation (ABC) approach. In particular, secure the airway and give high-concentration oxygen.

Take emergency bloods to investigate the cause but do not delay emergency treatment waiting for results. The most common acute causes of status epilepticus are hypoxia, stroke, metabolic abnormalities, alcohol intoxication/withdrawal, and poor anticonvulsant therapy adherence (in people with known epilepsy).

If the patient with convulsive status epilepticus has an individualised emergency management plan that is immediately available, administer medication as detailed in the plan. If no emergency management plan is immediately available, give a benzodiazepine immediately: use intravenous lorazepam if intravenous access and resuscitation facilities are immediately available; in the community, give buccal midazolam or rectal diazepam.

If convulsive status epilepticus does not respond to the first dose of benzodiazepine, seek expert guidance and either continue to follow the patient's emergency management plan (if immediately available) or give a second dose of benzodiazepine if the seizure does not stop within 5 to 10 minutes of the first dose.

If seizures continue after two adequate doses (established status), give an intravenous second-line agent (e.g., levetiracetam, phenytoin, sodium valproate).

If convulsive status epilepticus does not respond to a second-line treatment, consider trying an alternative second-line treatment option under expert guidance. If convulsive status epilepticus does not respond to the second-line options, a specialist may recommend transfer to intensive care for phenobarbital or general anaesthesia.

If you suspect non-convulsive status epilepticus, refer the patient to the neurology team for specialist clinical assessment and management.

Convulsive status epilepticus is defined by the National Institute for Health Care and Excellence in the UK as a convulsive seizure that continues for longer than 5 minutes.[1]National Institute for Health and Care Excellence. Epilepsies in children, young people and adults. April 2022 [internet publication]. https://www.nice.org.uk/guidance/ng217 [2]Trinka E, Cock H, Hesdorffer D, et al. A definition and classification of status epilepticus: report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia. 2015 Oct;56(10):1515-23. http://onlinelibrary.wiley.com/doi/10.1111/epi.13121/full http://www.ncbi.nlm.nih.gov/pubmed/26336950?tool=bestpractice.com Convulsive status epilepticus is an emergency and requires immediate medical attention.[1]National Institute for Health and Care Excellence. Epilepsies in children, young people and adults. April 2022 [internet publication]. https://www.nice.org.uk/guidance/ng217

Non-convulsive status epilepticus is a term used to denote a range of conditions in which seizure activity on electroencephalogram is prolonged and results in non-convulsive clinical symptoms (e.g., confusion, aphasia) without prominent motor symptoms.[2]Trinka E, Cock H, Hesdorffer D, et al. A definition and classification of status epilepticus: report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia. 2015 Oct;56(10):1515-23. http://onlinelibrary.wiley.com/doi/10.1111/epi.13121/full http://www.ncbi.nlm.nih.gov/pubmed/26336950?tool=bestpractice.com ​​[3]Shorvon S. What is nonconvulsive status epilepticus, and what are its subtypes? Epilepsia. 2007;48(suppl 8):35-8. https://onlinelibrary.wiley.com/doi/10.1111/j.1528-1167.2007.01344.x http://www.ncbi.nlm.nih.gov/pubmed/18329994?tool=bestpractice.com [4]Rüegg S. Nonconvulsive status epilepticus in adults: types, pathophysiology, epidemiology, etiology, and diagnosis. Neurology International Open 2017;1:E189-203. https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-0043-103383.pdf ​​ Non-convulsive status epilepticus can follow convulsive status epilepticus.

This topic focuses on the diagnosis and management of convulsive status epilepticus in adults.