- Tonic Clonic Seizure lasting > 5 minutes, OR
- Two or more seizures without full recovery (GCS = 15) in between (over any time period, usually within an hour or so)
Seizures in status epileptics are almost always tonic clonic. Status epilepticus is a medical emergency
- Primary brain injury - excitotoxic neuronal injury
- Secondary brain injury - e.g. from hyptension, hypoperfusion, hypoxia
- Excessive intracellular calcium leading to cell toxicity and death
- Aspiration pneumonitis
- Respiratory acidosis
- Aspiration pneumonitis
- Hypotension / Hypertension
- Lactic acidosis
Benzodiazepines are the first line management. Lorazepam IV is considered to be the best option. It has a quick onset and lasts several hours. In some studies it has also been shown to have superior seizure terminationg effects and reduced risk of sedation over diazepam. Out of hospital, or where IV access is not available, buccal or nasal midazolam is first line. Rectal diazepam is also used, but has slower onset, and its anti-seizure effects only last 20-30 minutes.
- Lorazepam 0.1 mg/Kg IV
- IV midazolam (0.1-0.3mg/Kg), clonazepam (0.5-1mg/Kg) and diazepam (0.15mg.Kg) are all useful alternatives in the above is not available
- No IV access: Midazolam 0.15-0.3mg/Kg IM or buccal or nasal, OR rectal diazepam 0.5mg/Kg (slowest onset)
- In addition: consider phenytoin (15-20mg/Kg IV) if not ceasing
- Phenobarbitone should be added as the second line agent if the above are still not effective. Patient must be ECG monitored.Dose of 10-20mg/Kg
In addition you should monitor the Airway, Breathing and Circulation vigilantly, particularly the airway. Start the patient on 15L high flow oxygen as soon as they begin seizing. Put a sats probe in place to monitor O2 saturations. Attempted to gain IV access.
If the seizure persists despite the above measures, then you will need to secure the airway via intubation. This should only be done in a critical care settings (e.g. Emergency Department, HDU, ICU), and you should sedate the patient as you would for any other intubation. This is usually done in the form of a rapid sequence induction, which involves a strong seating agent (e.g. propofol 20mg/Kg Iv), and a paralyzing agent (e.g. sexamethonium 2mg/Kg IV).
Propofol is also an acute antiepileptic. Once the patient has been sedated and paralyzed it is not possible to tell if the seizure has been terminated without the use of EEG monitoring. Ensure the patient has EEG monitoring to check on progress of the seizure.
Once the airway is secured and you have carried out the above measures, seek expert help (e.g. call neurologist).
Third line measures
The following may be attempted if the seizure continues
- Further dose of midazolam
- Further dose phenytoin up to a total of 30mg/Kg
- Thiopentone / profol infusion (likely to require intubation and possibly vasopressor support)
Try to find a cause and treat any underlying factors.