STATUS EPILEPTICUS
Minutes can seem like a lifetime when
a nurse encounters a patient having
a seizure
Outline
Introduction
Definition
Progression of SE
Terminology
Possible Signs of SE
Nursing Management of SE
Medications for SE
Role of Lacosamide in SE
Conclusion
Status Epilepticus (SE)
SE is a common neurological emergency.
SE is defined as continues seizure activity lasting more than 30 min or 2 or
more seizures in this duration without gaining consciousness between them.
However the operational definition has brought the time down to 5 min.
Recent data suggests that neuronal damage starts much early than 30
minutes.
ILAE Definitions of Status Epilepticus
Progression Of Status Epilepticus
Terminology
Impending SE : Term used for seizures between 5 and 30 minutes.
Convulsive SE : Manifests as GTCS, clonic or tonic-clonic seizures.
Non-convulsive SE : Manifests as confusional state, dementia,
hyperactivity with behavioral problems, fluctuating impairment of
consciousness.
Refractory SE: SE that has failed to respond to therapy, usually with
at least 2 (some have specified 3) medications.
New-onset Refractory Se (NORSE) : A distinct entity that can be
caused by almost any of the causes of SE in a patient without prior
epilepsy.
Possible signs of Status Epilepticus
Non-convulsive Convulsive
Aggression Convulsive syncope
Automatisms Repetitive decerebrate or
Blinking, Crying and Staring decorticate posturing
Delirium, Delusions and Psychosis
Involuntary movement disorders
Facial twitching, Aphasia
Psychogenic non-epileptic spells
(pseudo-seizures)
Nausea/vomiting
Amnesia,
Lawson T, Yeager S. Status Epilepticus in Adults: A Review of Diagnosis and Treatment. Crit Care Nurse. 2016 Apr;36(2):62-73 .
NURSING MANAGEMENT
OF
STATUS EPILEPTICUS
Time Is Brain
Status Epilepticus should always be
treated as an emergency and be
treated promptly!
Priorities for the first 0-5 min
Evaluation/treatment of airway with non-invasive management
Check initial vital signs and telemetry
Obtain intravenous access
Neurological examination
Finger-stick blood glucose
Administration of dextrose if hypoglycemic
Administration of benzodiazepine (first-line antiepileptic drug)
Fluid resuscitation if hypotensive
Priorities for the first 15 min
Intubation if airway or gas exchange is compromised
Second-line intravenous antiepileptic drug
Vasopressor support if hypotensive
Collect blood samples for laboratory tests (complete blood cell count,
calcium, magnesium, antiepileptic drug levels)
Electrocardiogram
Priorities for the first 15-60 min
Third-line antiepileptic drug for refractory status epilepticus
Electroencephalography
Computed tomography of the head
Lumbar puncture
Additional laboratory tests (liver function tests, troponin levels,
coagulation tests, arterial blood gases, comprehensive toxicology panel)
Magnetic resonance of the brain Within first 12-24 h
Continuous EEG Monitoring
The use of EEG is usually required for the treatment of SE.
Continuous EEG monitoring should be initiated within 1 hr. of SE onset
if ongoing seizures are suspected.
The duration of EEG monitoring should be at least 48 hr. in comatose
patients to evaluate for non-convulsive seizures.
Brophy, et al NCC 2012
Airway management
Monitor respiratory and oxygenation status to determine presence and
extend of problem and to initiate appropriate interventions.
Position patient (side lying) to maximize ventilation potential.
Identify patient requiring actual/potential airway insertion to facilitate
intubation as necessary.
Perform endotracheal or nasotracheal suctioning to maintain airway as
needed.
Maintaining Cerebral Tissue Perfusion
Maintain a patent airway until patient is fully awake after a seizure.
Provide oxygen during the seizure if cyanotic changes occurs.
Stress the importance of taking medications regularly.
Monitor serum levels for therapeutic range of medications.
Monitor patient for toxic adverse effects of medications.
Monitor platelet and liver functions for toxicity due to medications.
Preventing Injury
Provide a safe environment by padding side rails and removing clutter
which may be harmful to the patient.
Keep suction, Ambu bag, mouth piece at the bedside to maintain airway
and oxygenation if needed.
Place the bed in a low position.
Do not put anything in the patient’s mouth during a seizure.
Place the patient on side during a seizure to prevent aspiration.
Protect the patient’s head during a seizure.
If seizure occurs while ambulating or from chair, cradle head or provide
cushion/support for protection against head injury.
MEDICATIONS
FOR
STATUS EPILEPTICUS
Early Status Epilepticus:
Intravenous (IV) route available
0.07 mg/kg (usually 4 mg) IV bolus (maximum rate 2 mg/kg);
Lorazepam
if necessary can be repeated once.
5–10 mg IV bolus (maximum rate 5 mg/min); if necessary can
Diazepam
be repeated once up to 20 mg.
1 mg IV bolus (maximum rate 0.5 mg/min); if necessary can be
Clonazepam
repeated once after 5 min.
Drugs. 2015; 75: 1499–1521
Early Status Epilepticus:
If IV route is difficult or not possible:
10 mg buccal (5 mg in the elderly or in patients <50 kg); if
Midazolam necessary can be repeated once after 10 min.
Alternatively, use 10 mg/2 mL injection via buccal route.
10 mg intramuscularly (5 mg in the elderly or in patients <50
Midazolam
kg); if necessary can be repeated once after 10 min.
10 mg rectal (5 mg in the elderly or in patients <50 kg); if
Diazepam
necessary can be repeated once after 10 min.
Drugs. 2015; 75: 1499–1521
Established Status Epilepticus:
Phenobarbital 10 mg/kg (range 10–20) IV bolus infusion at a max. rate of 100 mg/min.
Phenytoin 18 mg/kg (range 15–20) IV bolus infusion at max. rate of 50 mg/min.
Fosphenytoin 15 mg PE/kg (range 15–20) IV bolus infusion at max. rate of 100 mg PE/min.
Valproate 30 mg/kg (range 15–30) IV bolus infusion at 3–6 mg/kg/min
Levetiracetam 30 mg/kg (range 30–60) IV bolus infused over 10 min.
Lacosamide 200–400 mg IV bolus infused over 3–5 min.
Drugs. 2015; 75: 1499–1521
Refractory Status Epilepticus:
2 mg/kg IV bolus infusion, repeated if necessary, and then followed by a continuous
Propofol infusion of 5–10 mg/kg/h initially, reducing to a dose sufficient to maintain a burst-
suppression pattern on the EEG (usually 1–3 mg/kg/h).
100–250 mg IV bolus infusion giver over 20 s with further 50-mg boluses every 2–3 min
Thiopental until seizure control, followed by a continuous IV infusion at a dose sufficient to maintain a
burst-suppression pattern on the EEG (usually 3–5 mg/kg/h).
5–15 mg/kg IV bolus, followed by a continuous IV infusion at a dose sufficient to maintain
Pentobarbital
a burst-suppression pattern on the EEG (usually 0.5–3 mg/kg/h).
0.1–0.3 mg/kg IV bolus infusion at max. rate of 4 mg/min initially, followed by a
Midazolam continuous IV infusion at a dose sufficient to maintain a burst-suppression pattern on the
EEG (usually 0.05–0.4 mg/kg/h).
Drugs. 2015; 75: 1499–1521
ROLE OF
LACOSAMIDE
IN
STATUS EPILEPTICUS
Lacosamide as an emerging new treatment option in SE
Lacosamide is a novel anticonvulsant drug that acts by slow inactivation
of the voltage-gated sodium channel, and is available as infusion.
Lacosamide is used as bolus dose of 200–400 mg over 3–5 min.
Advantages of Lacosamide
» Better tolerability
» Lack of drug-drug interactions
» Quickly cross the blood-brain barrier in intravenous solution
» Ease of use
Cases that suggest Lacosamide may have a role in SE
There are 10 single case reports and nine case series, reporting a total of
136 episodes of refractory SE treated with lacosamide.
All retrospective case series included patients with various forms of SE
in different stages.
» 50 % cases of Non-Convulsive SE
» 31 % focal SE
» 19 % Convulsive SE
The most commonly used bolus dose was 400 mg, followed by a daily
dose of 200–400 mg lacosamide.
Epilepsia, 54(3):393–404, 2013
Overview of all case reports of SE treated with IV LCM
SE Order
Study SE type Dose Outcome
(n) of LCM
Kellinghaus et al. (2009) 1 NCSE 3rd 200 mg (within 3–5 min) Responder after 5 min
Tilz et al. (2010) 1 CSE 6th 300 mg Responder after 30 min
Turpin-Fenoll et al. (2010) 1 NCSE 5th 25 mg twice daily Responder 1 week
Parkerson et al. (2011) 17 Focal SE --- 100 mg twice daily Responder
Chen et al. (2011) 1 Focal SE 4th 400 mg/day Responder
Two 400-mg bolus doses
Krause et al. (2011) 1 NCSE 3rd Responder
within 6 h
Granda- Mendez et al. (2011) 1 NCSE 3rd 100 mg/day Responder
LaRoche (2011) 1 NCSE 4th --- Responder
Torres-Cano et al. (2011) 1 NCSE 7th 200 mg/12 h Responder
Shiloh-Malawsky et al. (2011) 1 NCSE 8th 25 mg twice daily Responder after 5 days
Epilepsia, 54(3):393–404, 2013
Overview of all case series of SE treated with IV LCM
SE Order Dose
Study SE type Outcome
(n) of LCM (mg)
NCSE, CSE, 100% as 1st/2nd;
Kellinghaus (2011) 39 1-4 400
F0cal 95% as 3rd; 73% as 4th
NCSE
Koubeissi (2011) 4 3–5 50–100 100%
Goodwin et al. (2011) 9 NCSE, CSE 2-5 100–300 100%
Albers et al. (2011) 7 Focal SE 2-5 300-400 100%
NCSE, CSE,
€ofler et al. (2011) 31 200–400 Overall 81% Responders
F0cal
NCSE, CSE, 38% Complete seizure cessation
Cherry et al. (2012) 13 1-7 100–400
F0cal 54% with > 50% Reduction in seizure freq
Jain & Harvey (2012) 3 NCSE 5-7 50–200 100%
Mnatsakanyan (2012) 10 NCSE, CSE 2-8 200–300 70% Responder
Epilepsia, 54(3):393–404, 2013
Conclusion
Status epilepticus is an emergency & requires immediate treatment
Whether convulsive or non-convulsive in nature, emergent treatment
for status epilepticus should begin with management of airway,
breathing, and circulation followed by anti-epileptic drugs.
If you are concerned about seizures, consult neurology right away for
continuous EEG monitoring
