2. Definition
• Traditionally, status epilepticus is defined as
more than 30 minutes of either 1) continuous
seizure activity or 2) two or more sequential
seizures without full recovery of
consciousness between seizures
3. • The 30-minute definition is based on the
duration of convulsive status epilepticus that
may lead to permanent neuronal injury by
itself
• Since the majority of seizures are brief, and
once a seizure lasts more than 5 minutes it is
likely to be prolonged
4. Working definition
• status treatment protocols have used a 5-
minute definition to minimize both the risk of
seizures reaching 30 minutes and the adverse
outcomes associated with needlessly
intervening on brief, self-limited seizures
5.
6. Types
1) Convulsive status epilepticus consisting of repeated
generalized tonic–clonic (GTC) seizures with persistent
postictal depression of neurologic function between
seizures
2) Nonconvulsive status epilepticus:
• seizures produce a continuous or fluctuating “epileptic
twilight” state.
• Seizure activity can be seen on electroencephalogram
(EEG) without clinical findings associated with CSE.
• Some form of subtle motor movement like rhythmic
muscle twitches or tonic eye deviation can occur.
7. Potential underlying etiology
• Prolonged febrile seizures are the most frequent cause of SE in children. Account
for up to 35% of all episodes of SE.
• Metabolic disturbances: electrolyte abnormalities, hypoglycemia, inborn error of
metabolism, renal failure
• Central nervous system infection: meningitis, encephalitis, abscess
• Stroke: ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage,
cerebral sinus thrombosis
• Head trauma with or without epidural or subdural hematoma
• Drug toxicity
• Non-compliance with AEDs
• Hypoxia, cardiac arrest
• Hypertensive encephalopathy, posterior reversible encephalopathy syndrome
• Autoimmune encephalitis (i.e., anti-NMDA receptor antibodies, anti-VGKC complex
antibodies), paraneoplastic syndromes
8. Primary assessment and Stabilization
Air way: Secretion and trismus,
Snoring or Gurgling
Breathing: Perioral cyanosis,
Low O2 Saturation
Circulation: Tachycardia with
poor peripheral perfusion,
Hypotensive shock
Disability: Level of Consciousness
– GCS, Presence of Subtle motor
movements.
Exposure: Fever, toxin,
truma
Positioning ,
Suctioning
Intubation
Oxygen
Ventilation
NS bolus, Inotropes
Control of convulsion
Raised ICT management
Fever control
9. O-5 min : Stabilization
• Stabilization of patient (airway, breathing ,
circulation, neurologic exam)
• Start oxygen therapy
• Initial EEG if possible
• Collect finger stick 10D
• Attempt IV access, collect sample for electrolytes,
hemogram, toxicological screening
• Blood electrolytes specially Ca ++ level should
checked.
Collect finger stick blood glucose,
If < 60mg/dl give 2ml/kg 25 D in >2 yrs children, <2 yrs
4 ml /kg 10D
10. 5-20 min : First phase Initial therapy
Intra muscular
midazolam
10mg for >40 kg, 5mg for 12-40
kg,
Single
dose
Intravenous
lorazepam
0.1mg/kg/dose max 4mg Single
dose
Intravenous
Diazepam
0.15-0.2mg/kg/dopse max
10mg/dose
Single
dose
Alternative therapy
Intravenous
phenobarbital
15mg/kg over 20 min Single
dose
Rectal Diazepam 0.5mg/kg max 20mg /dose Single
dose
Intra nasal
midazolam
0.5 mg/kg(max 10mg)
11. • The benzodiazepines can control seizure in up
to 80% of patients
• All benzodiazepines work by potentiating the
neuroinhibitory effects of gamma-
aminobutyric acid (GABA).
• No difference has been found in time to
seizure cessation when comparing
intravenous with non-intravenous routes of
benzodiazepine administration.
12. 20-40 min : Second therapy phase
Intravenous
fosphenytoin
20mg/kg max
1500mg/dose
Single dose
Intravenous Valproic
Acid
40mg/kg max 3000
mg/dose
Single dose
Intravenous
Levetiracetam
60mg /kg max 4500mg/dose Single dose
Alternative therapy
Intravenous
phenobarbital
15mg/kg over 20 min Single dose
13. IV Fosphenytoin vs IV Levetiracitam vs
IV Sodium Valproate
• No clear winner
• But some preferences in different clinical
settings :
Forphenytoin Levetiracetam Valproate
Should not be used in
poisoning
Can cause hypotension
Good drug but very
limited pediatric data
Not preferred in less
than one year children,
in liver disease or in
suspected metabolic
disease
14. 40-60min : Third phase
• There is no clear evidence :
• Choices include repeat second line or
anesthetic dose of either thiopental,
midazolam, pentobarbital, propofol,
• With anesthetic drugs continuous EEG
monitoring is desirable
15. • No ICU and ventilation facility
available
• Another drug from the second line
can be loaded as third line. Like if
valproate was loaded as second line
then levetiracetam can be loaded as
third line
Repeat second
line
• Before starting general anaesthetics
patient should be shifted in ICU and
ventilation must be kept as potion.
• Initial 2 mcg/kg/min midaz can be
stared in non ventilated patient with
close vital monitoring. But if
increment is needed then ventilation
is an option
Anaesthetic
16. Third Therapy Treatment options
Drug Route does
Midazolam IV
Infusion
Loading: 0.15 mg/kg then
Infusion of 2 - 6 mcg/kg /min
Thiopental IV
Infusion
Loading : 3 to 5 mg / kg then
Infusion: 1 to 5 mg / kg / min
Pentobarbital IV
Infusion
Loading of 10 mg/kg then
Infusion : 1 to 3 mg /kg /hour
Propofol IV
Infusion
Loading of 2 mg/kg then
Infusion : 1 to 3 mg /kg /hour
17. Additional therapeutic option
• Steroid/Immunoglobulin /Plasma Exchange – Autoimmune
Encephalitis, FIRES
• Pyridoxine – In children < 2yrs . 50-100 mg IV bolous followed by 50
mg daily
•
• Magnesium Sulphate – initial 25-50 mg/kg IV (Max 2 grams, aiming for
plasma levels of 3.5 mmol/L
•
• KETOGENIC DIET - High fat, low carbohydrate, adequate protein diet
devised to mimic a fasting state and produce ketosis. It can be effective
for patients with drugresistant Epilepsy. Roll in FIRES. Mostly
underutilized and delay in start.
•
• Surgery - Surgical intervention can help for patients with particularly
refractory focal SE
•
• Inhalation Aneasthetic - Isoflurane and dexflurane. Limited experience
18. Indications for Mechanical Ventilation
• Glasgow coma scale score <8
• Respiratory depression (irregular jerky
breathing or apnea) due to SE or anesthetic
agents
• Fluid-refractory shock
• Raised intracranial pressure
• Difficult-to-maintain airway
19. Drugs used in intubation
• Midazolam & fentanyl: If blood pressure is
normal or in higher side
• Ketamin: If hypotension is present
• Rocuronium: Muscle relaxant
20. Raised ICP & Osmotherapy
Should be considered when:
Persistent altered sensorium
Refractory seizure
Other features of raised ICT
3% NaCL
• Less fluctuation of
blood pressure
• 0.5-1 ml/kg/hr
infusion
• Target sodium 145-155
Manitol
• More chance of
hypotension
• Contraindicated in
renal failure
21. Midazolam
Bolus 0.2 mg /kg then infusion at the rate of 1-2
μg/kg/min
Increasing 1 μg/kg/min, every 5-10 min, till seizures
stop, up to a maximum of 20μg/kg/min .
Tapering should be started 24-48 hours after seizure
stops at the rate of 1 μg/ kg/min, every 3-4 hours.
Drawback of midazolam is the apparent increased
propensity for seizure recurrence on tapering.
Risk of hypotension with higher dosed
22. • PROFOFOL
Very rapid onset and recovery even after prolonged
infusion.
Allows a much greater control of the level of anaesthesia
than is possible with thiopental/pentobarbital or
midazolam
Disadvantage in prolonged anaesthesia is the risk of the
propofol infusion syndrome (PRIS), potentially lethal toxic
effect on mitochondrial and cellular metabolic function.
The clinical features of PRIS include hypotension, metabolic
acidosis, lactic acidosis, rhabdomyolysis, hyperkalaemia,
hyperlipidaemia, bradycardia and cardiac dysfunction, and
renal failure.
23. • Ketamin
No cardiac depressant properties and does not cause
hypotension.
It is potentially neuroprotective, because of its
strong N-methyl-D-aspartate antagonist action.
Its safety in prolonged use is largely untested
24. Points to remember
• Time is money
• Initial stabilization is life saving
• No half loading of any anti epileptic
• Raised ICT may cause or effect of prolonged
seizure, so must addressed
• If PICU and ventilation facility available
Midazolam infusion should started in
refractory seizure early
25. Q-1
According to the operational definition seizure lasting longer than
what period of time is defined as status epilepticus?
A.5 minutes
B.10 minutes
C.30 minutes
D.60 minutes
26. Which of the following is the drug of first choice in a patient with
generalized convulsive status epilepticus?
A. Propofol
B. Lorazepam
C. Pentobarbitol
D. Valproate
27. Which of the following agents would be the most appropriate agent
to use as third-line therapy in a patient with refractory generalized
convulsive status epilepticus?
A. Valproate Infusion
B. Midazolam Infusion
C. Lidocaine
D. Paraldehyde
