Mayo Clinic 2 - 03 - Status Epilepticus

Front 1

Definition of status epilepticus

Back 1

Epileptic activity that persists for 30 minutes or more or repeated isolated seizures without recovery in between; operational definition is is seizure duration more than 5 minutes or 2 or more seizures with incomplete interictal recovery

Front 2

Refractory status epilepticus is defined as?

Back 2

Seizure that continues despite adequate doses of 2 appropriately selected AEDs, typically a benzodiazepine followed by fosphenytoin, valproic acid, or phenobarbital

Front 3

Incidence of status epilepticus

Back 3

6.8 to 41 cases per 100,000 annually

Front 4

Most common type of brain injury causing status epilepticus are?

Back 4

1. Vascular events (ischemic stroke)

2. Brain tumors

3. Meningitis or encephalitis

4. Trauma

5. Metabolic derangements

6. Acute febrile illnesses in children

Front 5

Status epilepticus becomes refractory in ____% of cases

Back 5

12% to 43% of cases

Front 6

Seizures are maintained primarily through which mechanisms?

Back 6

Excess excitation through Glutamate and NMDA receptors, as well as reduced inhibition through GABA receptors; the latter being increasingly thought to be the major mechanism leading to status epilepticus

Front 7

Mechanism of pharmacoresistance with sustained seizure activity? (3)

Back 7

1. Reduced GABA inhibition

2. Decreased availability of GABA receptors

3. Changes in gene expression altering ion channels, receptors, cell metabolism, and neuronal connectivity

Front 8

Diagnosis of status epilepticus is based on?

Back 8

1. Neurological exam consistent with seizure activity

2. Confirmed by EEG

Front 9

Generalized tonic-clonic status epilepticus is characterized by?

Back 9

1. Coma

2. Increased tone

3. Rhythmic jerking of extremities followed by a depressed level of consciousness, with or without a focal neurologic deficit

3. Lasting hours to days

Front 10

Emergency investigations in suspected status epilepticus?

Back 10

1. Assess ABCs

2. Glucose and oxygen status

3. Oxygen should be given, thiamine administered before correction of hypoglycemia

4. ABGs, LFTs, renal fxn, calcium and magnesium, AED levels

5. ECG and neuroimaging are recommended in all patients

6. Consider LP if fever, behavioural or speech changes, or no apparent cause

7. Pharmacological treatment should occur at the same time

Front 11

Pharmacologic treatment of status epilepticus first step:

Back 11

1. Lorazepam IV, 0.1mg/kg for adults, at a rate of 2 mg/min; alternatively midazolam IM 10mg if weight >40 kg

Front 12

Pharmacologic treatment of status epilepticus second step if first choice failed

Back 12

Phenytoin IV or fosphenytoin at 18-20 mg/kg; rate of 50mg/min for phenytoin and 150mg/min for fosphenytoin

Front 13

Alternative second step in step in pharmacological treatment of status epilepticus

Back 13

Valproic acid 20-25mg/kg IV loading dose, followed by 3-6mg/kg/min

Front 14

Third step in pharmacologic treatment of status epilepticus?

Back 14

Bolus 1/3 dose of previous dose phenytoin / fosphenytoin

Front 15

Fourth step in pharmacologic treatment of status epilepticus?

Back 15

1. Propofol at 3-5 mg/kg bolus followed by 5-10 mg/kg/h infusion

2. Midazolam 10mg bolus followed by 0.4mg/kg/h

3. Pentobarbital 2-3 mg/kg bolus followed by 3-5mg/kg/h

Front 16

When would you choose valproic acid over phenytoin in status epilepticus? (3)

Back 16

If the patient

1. Already takes valproic acid

2. Allergic to phenytoin

3. Hemodynamically unstable

Front 17

What does it mean to treat to burst suppression?

Back 17

To treat to a level at which all seizure activity is controlled

Front 18

In refractory status epilepticus how long should you treat?

Back 18

Treat to burst suppression for 12 to 48 hours, and then gradually withdraw sedation guided by EEG

Front 19

Causes of hypoxia in status epilepticus? (4)

Back 19

1. Mucous plugging

2. Pulmonary edema

3. Aspiration pneumonitis

4. Apnea

Front 20

Cause of leukocytosis in status epilepticus?

Back 20

Demargination and may be present in both serum and CSF

Front 21

Common injuries in status epilepticus?

Back 21

1. Lateral tongue bite

2. Posterior fractures or dislocations of the shoulder

3. Falls, resulting in various injuries

Front 22

Strongest predictor of of outcome in status epilepticus?

Back 22

1. Cause

2. Duration

Front 23

Mortality of status epilepticus?

Back 23

10% to 20% in status epilepticus, and an average of 32% in refractory cases