A life-threatening neurologic condition defined as 5 or more minutes of either continuous seizure activity or repetitive seizures without regaining consciousness.
Generalized convulsive status epilepticus (SE) in both its subtle and overt subtypes constitutes the most frequent variant.
Diagnosis of nonconvulsive SE can be difficult, but recognition is crucial because rapid termination helps prevent serious brain injury, especially in patients with impaired consciousness.
In most cases, treatment must precede any thorough investigation and must be initiated as soon as SE is suspected.
Treatment involves a stepwise medication approach aimed at aborting the clinical and electrographic seizures.
Carries a high mortality rate and may cause serious complications if not promptly treated.
Generalized convulsive and nonconvulsive status epilepticus (SE) are neurologic and medical emergencies defined as 5 or more minutes of either continuous seizure activity or repetitive seizures with no intervening recovery of consciousness. Traditionally SE was defined as 30 or more minutes; however, this time frame has been reduced to 5 minutes to emphasize the seriousness of the condition and the need to treat it urgently.
In the 2017 International League Against Epilepsy (ILAE) classification of seizures paper, convulsive seizures are termed "focal to bilateral tonic-clonic" seizures if they are focal in onset, and "generalized tonic-clonic" if they are generalized in onset. As the time of onset of a seizure may be unknown when a patient presents to medical attention in SE and as both types of convulsive SE are treated identically, for the purposes of this topic, the categories "generalized convulsive SE" and "nonconvulsive SE" will be used.
History and exam
Key diagnostic factors
- persistent or repetitive tonic-clonic seizures with altered level of consciousness (generalized convulsive SE)
- altered awareness/confusion (nonconvulsive SE)
Other diagnostic factors
- prolonged focal motor activity, or sensory or autonomic symptoms with intact consciousness (focal aware SE)
- low oxygen saturation
- nonadherence to anticonvulsant drugs
- chronic alcoholism
- refractory epilepsy
- toxic or metabolic causes
- processes leading to direct cortical structural damage
- drug use
1st investigations to order
- anticonvulsant drug blood level
- toxicology screen
- comprehensive metabolic panel
- electroencephalography (EEG)
Investigations to consider
- CT head
- lumbar puncture
- MRI head
generalized convulsive status epilepticus
nonconvulsive status epilepticus
focal aware (simple partial) status epilepticus
- Psychogenic nonepileptic SE
- Evidence-based guideline: treatment of convulsive status epilepticus in children and adults
- EFNS guideline on the management of status epilepticus in adults
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