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STATUS

EPILEPTICUS
Historical notes

• Life threatening epileptic condition

• First described – Babylonian text – first


millennium BC

• Early studies – SE – seizure > 1 hr


SE - DEFINITION

• continuous seizure activity > 30’


or
• two or more sequential seizures without full
recovery of consciousness between seizures
> 30’

Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the


Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. Aug
18 1993;270(7):854-9. [Medline].
SEIZURE > 5 min

DO NOT DELAY TREATMENT!!

Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged


seizures. Epilepsia. 2007;48 Suppl 8:96-8. [Medline].
EPIDEMIOLOGICA DATA

• 70% of SE - children
• 77% - first epileptic manifestation
• 5% from people diagnosed with epilepsy =
at least 1 SE

Aicardi J, Chevrie JJ. Convulsive status epilepticus in infants and children. A study of 239
cases. Epilepsia. Jun 1970;11(2):187-97. [Medline].

Hauser WA. Status epilepticus: epidemiologic considerations. Neurology. May 1990;40(5 Suppl 2):9-13. [Medline].

Waterhouse EJ, DeLorenzo RJ. Status epilepticus in older patients: epidemiology and treatment options. Drugs
Aging. 2001;18(2):133-42. [Medline].
SE - ETIOLOGIE
1. Symptomatic SE :
- acute provoked (head trauma, hypoxic,
infectios, vascular, toxic, metabolic, etc)
- pre-existant cerebral lesion
(non-progressive, progressive)

2. Criptogenic SE : - unic
- at the onset of epilepsy
- in people with epilepsy
FACTORS WHO PRECIPITATE SE

• sudden stop of AEDs


• low compliance to AEDs
• alcohol - excess
• infections
• evolution of underlying disease (tumour,
vascular malformation, metabolic disease)
SE - PATHOPHYSIOLOGY

Inhibition functional GABA


receptors changes
malfunction of a
mechanisms which stop
epileptic discharges
SE
ecessive stimulation of

Excitation excitatory NT (glutamate)


SE – natural course

1. Premonitory phase (serial sz) -


efficient treatament

2. Ongoing SE:
- early phase (compensation), <30 min,
nervous tissue-protected

- tardive phase (compensation exceeded)


>30-60 min, cerebral lesions
Meldrum BS, Horton RW. Physiology of status epilepticus in primates. Arch
Neurol. Jan 1973;28(1):1-9. [Medline].
SE – causes of cerebral lezions

- glutamate excitotoxicity
- Imbalance income / needs O2, G
- Other factors (hyperpyrexia,
SE hypoO2, hypotenssion, etc)
- Multiorganic insufficiency

BRAIN LESIONS
SE - CLASSIFICATION

1. CONVULSIVE
- generalized - generalized tonic-clonic – from the beginning
- partial onset
- tonic
- clonic
- myoclonic
- partial - simple/ complex partial
- Epilepsia partialis continua (Rasmussen,
Kojewnicow)
SE - CLASSIFICATION

2. NON-CONVULSIVE
- generalized - absence SE - typical
- atypical
- atonic SE
- partial - complex partial SE
SE - DIAGNOSTIC

1. Clinical signs
- positive for SE
- differential dg – other diseases
2. Clinical and neurological examination
3. EEG
SE = MEDICAL EMERGENCY!
SE - MANAGEMENT

1. Anamnesis
2. Clinical examination
3. Investigations
4. Check, correct vital parameters
5. Anticonvulsant treatment
1. ANAMNESIS

- head trauma
- signs/symptoms meningitis
- exposure to toxic substances
- chronic/acute diseases
- history of epilepsy, treatment, compliance
- antecedents
2. CLINICAL EXAMINATION

- vital signs
- temperature
- pupils
- meningeal signs
- signs of head trauma
- toxic syndromes
- intracranial hypertenssion signs
SE - MANAGEMENT

1. Check, correct vital parameters:


- airways
- breathing
- circulation
2. Position
3. Vascular access/ intraoseous/ endotracheal
4. Blood sampling
SE - MANAGEMENT
4. Blood sampling:
- CBC
-electrolites (including Ca, Mg)
- urea, creatinine
- bood sugar
- ASTRUP
- AEDs blood levels
- toxicologic determinations - blood, urine
(amphetamines, cocaine, phenotiazine, teophiline,
tricyclic antidepressants)
SE - MANAGEMENT

PRE-HOSPITAL CARE

1. Supportive care (ABCs)


2. Diazepam IV, PR 0,5mg/kg (respiration monitoring)
if seizures>4-5 min
3. Midazolam i.m. 0,08 mg/kg; rectal 0,3mg/kg
SE - TREATMENT
No intravenos acces correct acidosis, electrolits
Osseous canulation Yes glucose vs NaCl (2ml/kg), B6
No Yes Lorazepam (0,05-0,1mg/kg) SE>10’
Midazolam IM Diazepam (0,3 mg/kg)
Diazepam PR Phenytoin /Fos (15-20mg/kg) SE>25’

Intubate + ventilate SE>60’


Lidocaine Phenobarbital (10-20mg/kg)
Paraldehide Inhalatory anesthesia
(150-200 mg/kg) Refractory SE Barbituric coma
SE - COMPLICATIONS

1. Irreversible brain damage


2. Pulmonary: aspiration, obstruction,
hypoventilation, pulmonary edema
3. Cardiac: arrhythmia, arrest
4. Hypertermia
5. Rhabdomyolysis acute renal failure
SE – CAUSES OF DEATH

1. Complications
2. Underlying cause
3. Iatrogenic:
- ignoring vital signs
- ignoring complications
- excessive medication (hTA, hventil.)

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