STATUS EPILEPTICUS

Recognition

Definition (BMJ Best Practice)

• “A life- threatening neurological condition defined as 5 or more minutes of either continuous seizure activity or repetitive seizures without regaining consciousness”

Risk Factors

• Alcoholism
• Drug use
• Hypoxic episodes
• Metabolic disorders
• Non-adherence to anticonvulsant therapy
• Space occupying lesion
• Trauma

History

• If possible, ascertain if patient has:
  • Previous admissions with seizures or head trauma
  • Any operations or treatment for neurological conditions
  • Any allergies
  • Alcohol use

Classification

• Convulsive status epilepticus
  • Generalised
    • Tonic-clonic
  • Focal
    • Movement isolated to one group of muscles resulting in twitching or jerking of that body part
    • Consciousness will remain intact
• Nonconvulsive status epilepticus
  • Impaired awareness
  • Absence
  • Aware

General symptoms

• Convulsive status epilepticus
  • Airway obstruction due to reduced Glasgow Coma Scale
  • Hypoxic following airway obstruction
  • Tonic clonic movements of limbs and arms
• Nonconvulsive status epilepticus
  • Absence
  • Change in awareness
  • Delusions
  • Paranoia

General Signs

• In Tonic clonic seizures it will be difficult to ascertain physiological measurements such as saturations and blood pressure

Initial Assessment and Investigations

• ABCDE assessment
• Leave patient where they have collapsed but ensure safety
• Assess patient’s airway – call an anaesthetist if airway compromised
• Call for senior help
• Monitor oxygen saturations and respiratory rate
  • If patient is hypoxic give Oxygen (O₂) to achieve target saturations. Initially give 15 L/min via a reservoir mask if the patient is acutely unwell
• Target saturations:
  • 94 - 98% for patients not at risk of hypercapnic respiratory failure
  • 88 - 92% for patients at risk of hypercapnic respiratory failure due to conditions such as Chronic Obstructive Pulmonary Disease (COPD)
• Monitor respiratory rate
• Arterial blood gas (ABG) if concerned about patient’s ventilation but only if the patient has stopped tonic-clonic movement
• Obtain intravenous access by placing 2 large bore cannulae in the antecubital fossa but only if the patient has stopped tonic-clonic movement. Take blood to check Full Blood Count (FBC), Urea and Electrolytes (U&Es), Magnesium and Phosphate, Liver Function Tests (LFTS), toxicology
• Check Capillary Refill Time (CRT) - hold for five seconds and refilling should occur in 3 seconds
• Assess pulse rate, rhythm and character
• Monitor heart rate and blood pressure if possible
• Ask nursing team to prepare pharmacological management as described below
• Check pupils are equal and reactive
• Assess Glasgow Coma Scale or ACVPU using the NEWS2 chart
• Check patient’s temperature and blood glucose
• Examine patient’s abdomen and legs
• Check patient from head to toe for injuries from fall
• Discuss venous thromboembolism prophylaxis with senior, due to fall

Response

Management

• Immediate pharmacological management (NICE Protocols for treating convulsive status epilepticus in adults and children)
  • Convulsive or Impaired Awareness Nonconvulsive
    • Early status (0-10 minutes)
      • Intravenous access or intraosseous access
        • Lorazepam 0.1 mg/kg intravenously (IV)
          • Repeat once after 10-20 minutes
        • Consider thiamine and glucose IV
      • No Intravenous access
        • Diazepam 10 mg Per Rectum (PR)
          • Repeat once after 15 minutes
    • Established status (10-20 minutes)
      • Phenytoin infusion
        • See trust guidelines for dose
    • Refractory status (> 20 minutes)
      • General Anaesthesia

Referrals

• Discuss with senior member of the team
• Contact critical care outreach team
• Consider referral to Intensive Care Unit (ICU) if:
  • Failure to respond to medical management- contact prior to starting IV phenytoin infusion
  • Patient requires ventilator support
  • Patient requires blood pressure support
  • Deterioration of blood gas following medical management

Future management

• Review by neurologists regarding future management and prophylaxis
• Future investigations
  • Computed Tomography (CT) head
  • Electroencephalography (EEG) to differentiate the subgroup of epilepsy
  • Electrocardiogram (ECG)
    • Review ECG for any signs of ischaemia following prolonged episode of status epilepticus