Acute seizure Status epilepticus

Surat Tanprawate, MD, MSc(London), FRCP(T) Division of Neurology, Chiang Mai University

Outline of my talk
Introduction and seizure diagnosis Treatment of status epilepticus

Seizure and Epilepsy

Seizure

the clinical manifestation of an abnormal and hypersynchronous discharge of a population of cortical neurones

Epilepsy

a tendency toward recurrent seizures unprovoked by systemic or neurologic insults least two unprovoked seizures at least 24 hours apart

Acute symptomatic seizure

a seizure occurring after identiable cause (metabolic, stroke, traumatic brain injury or infection)

Patient come with clinically suspected seizure

Known case epilepsy with recurrent seizure Seizure mimicker

First diagnosed seizure

Status epilepticus

Cause?

Treatment options
Treatment cause AED?

Seizure or Not seizure

Seizure mimicker convulsive syncope pseudo-seizure movement disorder: myoclonus,
chorea

hypnic jerk

Movement disorder mimic seizure

Myoclonus is a great seizure mimicker

Identify cause of seizure (symptomatic seizure)

Acute symptomatic seizure Remote symptomatic seizure

Stroke Metabolic disturbances CNS infection Trauma Drug Toxicity Hypoxia

Pre-existing epilepsy Ethanol abuse Old CVA Relatively longstanding tumors

What should we do?

Evaluate ABCD, and check basic lab, If seizure is not stop; start AEDs Complete general, neuro-exam,
investigation to identify cause intubation or oxygen therapy if indicate

Brain imaging if indicate

Status epilepticus

Status Epilepticus

How to dene status...

1981, ILAE (International League against Epilepsy) a seizure that persists for a sufcient length of time or is repeated frequently enough that recovery between attacks does not occur Premonitory status: increase in the usual frequency or severity of their seizures may precede status epilepticus need for emergency management

Status Epilepticus

How to dene status...

The Epilepsy Foundation of Americas Working Group on SE (1993)

continuous seizure > 30 minutes > 2 seizures with impaired

consciousness

Compensated

Decompensated

New proposed denition of SE

Status Epilepticus Cooperative Study
group (1998)

SE > 10 minutes Lowenstein DH (1999) SE > 5 minutes

Classication of status epilepticus

1.Generalized convulsive status epilepticus 2.Non-convulsive SE 3.Simple partial SE
(Treiman 1980)

1. Overt 2. Subtle 3. Electrical generalized generalized generalized convulsive SE convulsive SE convulsive SE

Generalized convulsive status epilepticus

(Treiman 1980)

Generalized seizure

Non-convulsive SE

Complex partial SE Absence SE

Simple partial SE

Epilepsia partialist continua

(EPC)

Look for hyperglycemia

Complication of SE
Acidosis Cerebral edema Hypoglycemia Other: arrhythmia, hyperthermia,

hyperkalemia, DIC, rhabdomyolysis, myoglobinuria, renal failure

Management of SE

Key
treat early as possible step up AED is depended on stage of
SE

add on therapy is needed monitor EEG regularly, even if no

obvious seizure

Dene stage of the status epilepticus

Pre-monitory status(0-5 min) Early status(5-30 min) Established status(30-60 min) Refractory status(>60 min)

Drug used
diazepam, phenytoin(Dilantin), valproic
acid(Depakine), levetirazetam(Keppra) thiopental

Phenobarbital, propofol, midazolam, Topiramate(feed)

drug use depend on stage of status

stage of status
Premonitory (0-5 min)

AED treatment
Diazepam (i.v. bolus)

Early (5-30 min)

Diazepam (i.v. bolus) followed by phenytoin (iv load) or sodium valproate (i.v. loading) or levetiracetam (i.v.)

Established (30-60 min)

half dose i.v. load of previous drug, if seizure dont stop, load another drug

Refractory ( > 60 min)

Propofol (i.v.), or midazolam (i.v.), or thiopental (i.v.) or phenobarbital (i.v.) or topiramate (feed)

Diazepam
diazepam 10 mg (2-5mg/min) max 10 mg per dose can be repeated 2 doses

Phenytoin

Vial: 250 mg/5 ml/vial

0.9% NaCl (dont use infusion pump)

starting dose: 20 mg/kg (rate < 1 mg/kg/min) maintenance: 5-8 mg/kg/day e.g. weight 50 kg

Dilantin 1000 mg+0.9%NSS 100 cc iv drip in 20 min. then Dilantin 100 mg+0.9%NSS 100 cc iv drip in 15 min

Valproic acid

Vial: 400 mg/4 ml/vial

0.9% NaCl or 5% Dextrose

starting dose: 20-30 mg/kg (rate < 50 mg/min) maintenance: 1-2 mg/kg/hr (max 60 mg/kg/day) e.g. weight 50 kg

Depakine 1000 mg+0.9%NSS 100 cc iv drip in 30 min. then Depakine 100 mg/hr (10 cc/hr)

warning: hepatotoxicity

Midazolam

Vial: 1 mg/ml/vial, 5 mg/ml/vial, 15mg/ 3ml

0.9% NaCl or 5% Dextrose/w

starting dose: 0.1-0.3 mg/kg bolus (rate < 4 mg/min) maintenance: 0.05-0.4 mg/kg/hr e.g. weight 50 kg

Midazolam 5 mg iv bolus then + Midazolam (1:1) iv drip 5 cc/hr (0.1 mg/kg/hr)

Levetiracetam (Keppra)

Vial: 500 mg/5 ml 0.9% NaCl or 5% Dextrose/w 100 ml starting dose: 2,000-4,000 mg/kg in 15 min maintenance: 10-30 mg/12 hr e.g. weight 50 kg

Keppra 2000 mg iv in 15 min then 1000 mg iv q 12 hour

Propofol

Vial: 10 mg/ml

5% Dextrose/w

starting dose: 2 mg/kg bolus maintenance: 5-10 mg/kg/hr e.g. weight 50 kg

Propofol (2:1) iv 100 mg then 250 mg/hr

Consult is required

Thiopentone

Vial: 1 g/vial starting dose: 100-250 mg in 20 min then 50 mg q 2-3 min until seizure stop maintenance: 3-5 mg/kg/hr

Consult is required

Phenobarbital

Vial: 200 mg/4 ml in sterile water 10 ml

5% Dextose

starting dose: 20 mg/kg (rate < 100 mg/min) maintenance: 1-4 mg/kg/day

Topiramate for SE
Clinical trial: 500 mg every 12 hours Effective dose: 300-1600 mg/day
noso/orogastric feed for 2 days then 150 mg-750 mg every 12 hours

Monitoring
Tapering off AED seizure stop > 24 hours Burst suppression on EEG > 24
hours

Slow tapering off AED if seizure recur, increase AED dose

enough to control seizure