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http://www.aafp.org/afp/2003/0801/p469.

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Management of Status Epilepticus JOSEPH I. SIRVEN, M.D., and ELI !"E#H $!#ERHO%SE, M.D., Ma&o 'linic, Scottsdale, !(i)ona* Vi(ginia 'ommon+ealt, %ni-e(sit& Sc,ool of Medicine, Ric,mond, Vi(ginia Am Fam Physician. .//0 !ug 1*23405672897:2. Status epilepticus is an inc(easingl& (ecogni)ed pu;lic ,ealt, p(o;lem in t,e %nited States. Status epilepticus is associated +it, a ,ig, mo(talit& (ate t,at is la(gel& contingent on t,e du(ation of t,e condition ;efo(e initial t(eatment, t,e etiolog& of t,e condition, and t,e age of t,e patient. #(eatment is e-ol-ing as ne+ medications ;ecome a-aila;le. #,(ee ne+ p(epa(ations<fosp,en&toin, (ectal dia)epam, and pa(ente(al -alp(oate<,a-e implications fo( t,e management of status epilepticus. Ho+e-e(, (andomi)ed cont(olled t(ials s,o+ t,at ;en)odia)epines 4in pa(ticula(, dia)epam and lo(a)epam5 s,ould ;e t,e initial d(ug t,e(ap& in patients +it, status epilepticus. Despite t,e paucit& of clinical t(ials compa(ing medication (egimens fo( acute sei)u(es, t,e(e is ;(oad consensus t,at immediate diagnosis and t(eatment a(e necessa(& to (educe t,e mo(;idit& and mo(talit& of t,is condition. Mo(eo-e(, in-estigato(s ,a-e (epo(ted t,at status epilepticus often is not conside(ed in patients +it, alte(ed consciousness in t,e intensi-e ca(e setting. In patients +it, pe(sistent alte(ation of consciousness fo( +,ic, t,e(e is no clea( etiolog&, p,&sicians s,ould ;e mo(e =uic>l& p(epa(ed to o;tain elect(oencep,alog(ap,& to identif& status epilepticus. P,&sicians s,ould (el& on a standa(di)ed p(otocol fo( management of status epilepticus to imp(o-e ca(e fo( t,is neu(ologic eme(genc&. Status epilepticus is an unde(9(ecogni)ed ,ealt, p(o;lem associated +it, su;stantial mo(;idit& and mo(talit&. !n estimated 1?.,/// cases occu( pe( &ea( in t,e %nited States, (esulting in 7.,/// deat,s and an inpatient cost of @0.3 to @: ;illion pe( &ea(.1A0 #,is (e-ie+ concent(ates on t,e clinical management of status epilepticus 4pa(ticula(l& con-ulsi-e status epilepticus5, t,e t,eo(etic and clinical conside(ations in-ol-ed in c,oosing an antiepileptic d(ug to t(eat t,is eme(genc& situation, and t,e consensus p(otocol de-ised ;& t,e Epileps& Boundation of !me(ica 4EB!5 $o(>ing C(oup on Status Epilepticus. Definition, 'lassification, and Epidemiolog& DEBINI#ION ! decade ago, t,e EB! con-ened a +o(>ing g(oup to define status epilepticus.7 #,e& desc(i;ed t,is condition as t+o o( mo(e se=uential sei)u(es +it,out full (eco-e(& of consciousness ;et+een sei)u(es, o( mo(e t,an 0/ minutes of continuous sei)u(e acti-it&.7 #,is definition is gene(all& accepted, alt,oug, some in-estigato(s conside( s,o(te( du(ations of sei)u(e acti-it& to constitute status epilepticus. P(acticall& spea>ing, an& pe(son +,o eD,i;its pe(sistent sei)u(e acti-it& o( +,o does not (egain consciousness fo( fi-e minutes o( mo(e afte( a +itnessed sei)u(e s,ould ;e conside(ed to ,a-e status epilepticus. 'L!SSIBI'!#ION S'HEME

!lt,oug, t,e(e is no consensus o-e( a classification s&stem fo( status epilepticus, classification is necessa(& fo( app(op(iate management of t,e condition ;ecause effecti-e management depends on t,e t&pe of status epilepticus. In gene(al, t,e -a(ious s&stems c,a(acte(i)e status epilepticus acco(ding to +,e(e t,e sei)u(es a(ise<f(om a locali)ed (egion of t,e co(teD 4pa(tial onset5 o( f(om ;ot, ,emisp,e(es of t,e ;(ain 4gene(ali)ed onset5. #,e ot,e( maEo( catego(i)ation ,inges on t,e clinical o;se(-ation of o-e(t con-ulsions* t,us, status epilepticus ma& ;e con-ulsi-e o( noncon-ulsi-e in natu(e. Va(ious app(oac,es to classif&ing status epilepticus ,a-e ;een suggested.?A: One -e(sion? classified status epilepticus into gene(ali)ed 4tonic9clonic, m&oclonic, a;sence, atonic, a>inetic5 and pa(tial 4simple o( compleD5 status epilepticus. !not,e( -e(sion2 di-ides t,e condition into gene(ali)ed status epilepticus 4o-e(t o( su;tle5 and noncon-ulsi-e status epilepticus 4simple pa(tial, compleD pa(tial, a;sence5. #,e t,i(d -e(sion: ta>es a diffe(ent app(oac,, classif&ing status epilepticus ;& life stage 4confined to t,e neonatal pe(iod, infanc& and c,ild,ood, c,ild,ood and adult,ood, adult,ood onl&5. EPIDEMIOLOCF Status epilepticus of pa(tial onset accounts fo( t,e maEo(it& of episodes.1A7,3A1. One epidemiologic stud&1 on status epilepticus found t,at 28 pe(cent of episodes in adults and 27 pe(cent of episodes in c,ild(en +e(e pa(tial onset, follo+ed ;& seconda(il& gene(ali)ed status epilepticus in 70 pe(cent of adults and 02 pe(cent of c,ild(en. #,e incidence of status epilepticus +as ;imodall& dist(i;uted, occu((ing most f(e=uentl& du(ing t,e fi(st &ea( of life and afte( t,e age of 2/ &ea(s.1,. !mong adults, patients olde( t,an 2/ ,ad t,e ,ig,est (is> of de-eloping status epilepticus, +it, an incidence of 32 pe( 1//,/// pe(sons pe( &ea(.1A0 !mong c,ild(en 1? &ea(s o( &ounge(, infants &ounge( t,an 1. mont,s ,ad t,e ,ig,est incidence and f(e=uenc& of status epilepticus.1 ! -a(iet& of etiologies accounted fo( t,e condition. In adults, t,e maEo( causes +e(e lo+ le-els of antiepileptic d(ugs 407 pe(cent5 and ce(e;(o-ascula( disease 4.. pe(cent5, including acute o( (emote st(o>e and ,emo((,age.1A0 #,e (ate of mo(talit& f(om status epilepticus 4defined as deat, +it,in 0/ da&s of status epilepticus5 +as .. pe(cent in t,e Ric,mond stud&.1,10 #,e mo(talit& (ate among c,ild(en +as onl& 0 pe(cent, +,e(eas t,e (ate among adults +as .2 pe(cent.1,10,17 #,e elde(l& population ,ad t,e ,ig,est (ate of mo(talit& at 03 pe(cent.1,10,17 #,e p(ima(& dete(minants of mo(talit& in pe(sons +it, status epilepticus +e(e du(ation of sei)u(es, age at onset, and etiolog&.10,17 Patients +it, anoDia and st(o>e ,ad a -e(& ,ig, mo(talit& (ate t,at +as independent of ot,e( -a(ia;les.10A1? Patients +it, status epilepticus occu((ing in t,e setting of alco,ol +it,d(a+al o( lo+ le-els of antiepileptic d(ugs ,ad a (elati-el& lo+ mo(talit& (ate. In nonfatal cases, status epilepticus is associated +it, significant mo(;idit&. 'ogniti-e decline follo+ing an episode, as documented ;& neu(ops&c,omet(ic testing, is a +ell9 esta;lis,ed end (esult of p(olonged seconda(il& gene(ali)ed and pa(tial status epilepticus.12 S&stemic Pat,op,&siolog& Cene(ali)ed con-ulsi-e status epilepticus is associated +it, se(ious s&stemic p,&siologic c,anges (esulting f(om t,e meta;olic demands of (epetiti-e sei)u(es. Man& of t,ese s&stemic c,anges (esult f(om t,e p(ofound autonomic c,anges t,at occu( du(ing status epilepticus, including tac,&ca(dia, a((,&t,mias, ,&pe(tension, pupilla(& dilation, and ,&pe(t,e(mia ;ecause of t,e massi-e cat9ec,olamine disc,a(ge associated +it, continuous gene(ali)ed sei)u(es. S&stemic c,anges (e=ui(ing medical inte(-ention include ,&poDia, ,&pe(capnia,

,&pogl&cemia, meta;olic acidosis, and ot,e( elect(ol&te distu(;ances. #a;le 1:,1:A18 summa(i)es t,e p,&siologic c,anges t,at occu( du(ing status epilepticus. #!"LE 1 S&stemic 'omplications of Cene(ali)ed 'on-ulsi-e Status Epilepticus Meta;olic Lactic acidosis H&pe(capnia H&pogl&cemia H&pe(>alemia H&ponat(emia 'SBGse(um leu>oc&tosis !utonomic H&pe(p&(eDia Bailu(e of ce(e;(al auto(egulationH Vomiting Incontinence Renal !cute (enal failu(e f(om (,a;dom&ol&sisH M&oglo;inu(iaH 'a(diacG(espi(ato(& H&poDia !((,&t,mia Hig, output failu(eH Pneumonia 'SB I ce(e;(ospinal fluid. H<Ra(e complications of status epilepticus. Info(mation f(om (efe(ences : and 1: t,(oug, 18. Management of Status Epilepticus CENER!L ME!S%RES #,e t(eatment of status epilepticus in-ol-es t,e use of potent int(a-enous medications t,at ma& ,a-e se(ious ad-e(se effects. #,e(efo(e, t,e fi(st step in managing t,e condition is to asce(tain t,at t,e patient ,as tonic9clonic status epilepticus, and t,at p(olonged o( (epetiti-e sei)u(es ,a-e occu((ed. ! single gene(ali)ed sei)u(e +it, complete (eco-e(& does not (e=ui(e t(eatment. Once t,e diagnosis of status epilepticus is made, ,o+e-e(, t(eatment s,ould ;e initiated immediatel&. Necessa(& inte(-entions include maintaining oD&genation and ci(culation, assessing t,e etiolog& and la;o(ato(& e-aluations, o;taining int(a-enous access, and initiating d(ug t,e(ap&. P,&sicians fi(st s,ould assess t,e patientJs ai(+a& and oD&genation. If t,e ai(+a& is clea( and intu;ation is not immediatel& (e=ui(ed, ;lood p(essu(e and pulse s,ould ;e c,ec>ed and oD&gen administe(ed. In patients +it, a ,isto(& of sei)u(es, an attempt s,ould ;e made to dete(mine +,et,e( medications ,a-e ;een ta>en (ecentl&. ! sc(eening neu(ologic eDamination s,ould ;e pe(fo(med to c,ec> fo( signs of a focal int(ac(anial lesion.

O;taining int(a-enous access is t,e neDt step, and ;lood s,ould ;e sent to t,e la;o(ato(& fo( measu(ement of se(um elect(ol&te, ;lood u(ea nit(ogen, glucose, and antiepileptic d(ug le-els, as +ell as a toDic d(ug sc(een and complete ;lood cell count. Isotonic saline infusion s,ould ;e initiated. "ecause ,&pogl&cemia ma& p(ecipitate status epilepticus and is =uic>l& (e-e(si;le, ?/ mL of ?/ pe(cent glucose s,ould ;e gi-en immediatel& if ,&pogl&cemia is suspected. If t,e p,&sician cannot c,ec> fo( ,&pogl&cemia o( t,e(e is an& dou;t, glucose s,ould ;e administe(ed empi(icall&. #,iamine 41// mg5 s,ould ;e gi-en along +it, t,e glucose, ;ecause glucose infusion inc(eases t,e (is> of $e(nic>eJs encep,alopat,& in suscepti;le patients. !fte( administ(ation of oD&gen, ;lood gas le-els s,ould ;e dete(mined to ensu(e ade=uate oD&genation. Initiall&, acidosis, ,&pe(p&(eDia, and ,&pe(tension need not ;e t(eated, ;ecause t,ese a(e common findings in ea(l& status epilepticus and s,ould (esol-e on t,ei( o+n +it, p(ompt and successful gene(al t(eatment. If sei)u(es pe(sist afte( initial measu(es, medication s,ould ;e administe(ed. Imaging +it, computed tomog(ap,& is (ecommended afte( sta;ili)ation of t,e ai(+a& and ci(culation. If imaging is negati-e, lum;a( punctu(e is (e=ui(ed to (ule out infectious etiologies. ROLE OB ELE'#ROEN'EPH!LOCR!PHF Elect(oencep,alog(ap,& 4EEC5 is eDt(emel& useful, ;ut unde(utili)ed, in t,e diagnosis and management of status epilepticus. !lt,oug, o-e(t con-ulsi-e status epilepticus is (eadil& diagnosed, EEC can esta;lis, t,e diagnosis in less o;-ious ci(cumstances. Resea(c,e(s in one stud&./ used EEC to diagnose status epilepticus in 0: pe(cent of patients +it, alte(ed consciousness +,ose diagnosis +as unclea( on t,e ;asis of clinical c(ite(ia. ! su(p(ising num;e( of patients ,ad no clinical signs of status epilepticus, and EEC +as necessa(& to esta;lis, t,e diagnosis. EEC also can ,elp to confi(m t,at an episode of status epilepticus ,as ended, pa(ticula(l& +,en =uestions a(ise a;out t,e possi;ilit& of (ecu((ent episodes of mo(e su;tle sei)u(es. In anot,e( stud&,.1 in-estigato(s monito(ed patients fo( at least .7 ,ou(s afte( clinical signs of status epilepticus ,ad ended. #,e& found t,at nea(l& one ,alf of t,ei( patients continued to demonst(ate elect(o9g(ap,ic sei)u(es t,at often ,ad no clinical co((elation. #,

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