Approach to seizure and status epilepticus patient

Status epilepticus is a single seizure ≥5 minutes in length or two or more seizures without recovery of consciousness between seizures. Status epilepticus is a neurologic emergency, and treatment should be initiated in all patients with continuous seizure activity lasting more than 5 minutes.

Clinical presentations

• Abrupt onset seizures

• Altered mental status

• Postictal drowsiness

• Tongue biting

Differential diagnoses

• Epilepsy

• Meningitis

• Encephalitis

• Malaria

• Space occupying lesion

• Alcohol withdrawal

• Isoniazid toxicity

• Intracranial hemorrhage

• Metabolic abnormalities - hyponatremia

• Eclampsia

• Acute hydrocephalus

Investigations

• Blood Glucose

• Electrolytes: (Sodium, Potassium, Chloride, Magnesium and Calcium)

• ECG

• Bedside ultrasound

• Blood gases

• Malaria Test

• Serum creatinine and urea

• Lactate levels

• Pregnancy test (females)

• Toxicology screening

• CT Head

Non-pharmacological management

• Protect patient from injury (If possible place in left lateral position to reduce aspiration risks), Don’t place tongue depressor

• Perform both primary and secondary assessment and provide necessary interventions

• Give Oxygen if needed

• Do bedside random blood sugar test

• Establish IV access for administration of anticonvulsants, if unable use the rectal route

• Connect the patient to the cardiac monitor to obtain vital signs

Pharmacological management

I. Active seizure 0–5 minutes

Supportive care

IV access, monitors, maintain airway, oxygen therapy. Check point-of-care glucose and provide:

A: dextrose 5% (IV); if glucose is ≤ 3.5mmol/L

AND

A: diazepam (IV) 0.15–0.2mg/kg. Maximum 10mg (Rectal dose: 0.2–0.5mg/kg) repeat every 5 minutes up to 3 doses

OR

D: midazolam (IV): 0.1mg/kg repeat every 5 minutes up to 3 doses

II. Established status epilepticus 5–10 minutes

B: phenobarbitone (IV): Adults 20mg/kg slowly (max 50mg/min); Paediatrics 20mg/kg slowly (max 30mg/min)

OR

C: phenytoin (IV) Adults 20mg/kg slowly (max 50mg/min); Paediatrics 20mg/kg slowly (max 30mg/min)

Consider INTUBATION if patient still seizing

C: thiopental (IV): Adult 3–6mg/kg loading dose then 25–100mg infusion as needed; Paediatrics 2–5mg/kg loading dose

OR

D: propofol (IV): Adults 2mg/kg loading dose then 2–10mg/kg/hour; Paediatrics 3mg/kg loading dose, then 7.5–18mg/kg/hr

OR

D: midazolam (IV): Adult 0.2mg/kg loading dose then 0.1–0.2mg/kg/hour; Paediatrics 0.1mg/kg then infusion 0.06–0.4mg/kg/hour

Disposition

Intensive care unit admission or refer to the higher health facility with ICU/HDU capacity.