Management of Status Epilepticus

Introduction

Tonic-clonic status epilepticus (continuing or recurrent seizures over 30 minutes, or without recovery) is a medical emergency with a 10–15% mortality rate. There is a risk that seizures will cause cerebral damage if not controlled within 30 minutes of onset.

Pre-status epilepticus is a phase of accelerating seizures which usually takes place prior to the development of frank status epilepticus. Status epilepticus can be avoided if treatment is given at this stage.

This guideline outlines the general management of tonic-clonic status epilepticus in adults and is based on the SIGN guideline for diagnosis and management of epilepsy in adults. Treatment may differ in individual clinical circumstances.

Assessment / monitoring

See flow chart below for general assessment and monitoring. Treatment should not be delayed. Note timings throughout in order to assess when to escalate treatment. Assess patient for possible causes such as:

• Poor compliance with Anti-Epileptic Drugs (AEDs), change of drug therapy, drug interactions
• Infection
• Acute cerebral insult (encephalitis, meningitis, trauma)
• Cerebral tumour (often frontal lobe)
• Drug overdose (e.g. antidepressants)
• Drug withdrawal (e.g. alcohol, benzodiazepines etc.)
• Pseudostatus should be considered. If blood gases are normal or suggest hyperventilation, despite apparent prolonged major seizures then pseudostatus is likely. Diagnosis is aided by EEG. Get neurological advice before proceeding to general anaesthesia and ITU.

Management of Status Epilepticus / Pre-status Epilepticus

Prevention: Carers should treat serial or prolonged seizures in the community with rectal diazepam or intranasal / buccal midazolam according to an agreed protocol (protocol must include advice on when to transfer to hospital).

For status epilepticus see flow chart below for management. Do not delay treatment.

For pre-status epilepticus, do not delay treatment. Give lorazepam IV or diazepam rectally as per flowchart. AED treatment needs to be restored / maintained as quickly as possible. If in doubt about compliance give one complete dose of all usual AEDs. If no information on previous treatment or seizures continue to accelerate, proceed to additional AED treatment (as per status epilepticus guideline).

For both status epilepticus and pre-status epilepticus assess aetiology and correct if possible.

• Flowchart Patients with generalised tonic-clonic status epilepticus

Adapted with permission from SIGN 70: Diagnosis and Management of Epilepsy in Adults. A national clinical guideline (April 2003).

Other

Initiating Long-term Anti-epileptic Drugs

In status epilepticus, immediate treatment is required to reduce the risk of cerebral damage. Once seizures are controlled, consideration should be given to long-term anti-epileptic treatment. Recommendations on appropriate therapy should be sought from an epilepsy specialist, however the patient should not be left untreated while waiting for specialist advice.

Patients who do not present with status epilepticus but who require long-term anti-epileptic drugs should be referred to an epilepsy specialist / neurologist (usually outpatient service) and ideally no medication should be started in the meantime. (SIGN Guideline Number 70 recommends that in epilepsy, treatment should only be initiated by a specialist.) For elderly patients current practice of management by a physician specialising in medicine for the elderly should continue, with specialist neurological advice available when necessary.

Generally long-term anti-epileptic therapy is not usually indicated in patients:

• If the cause of the seizures is known and can either be withdrawn or corrected or
• As prophylaxis therapy following an acute brain injury

Content last Reviewed April 2016