Status Epilepticus

Content of This Page

 1- Introduction

2- Causes

3- Symptoms

4- Investigations & Lab Results

5- Complications

6- Treatment

7- Prognosis

 

Introduction

Status Epilepticus  is a life-threatening neurological emergency characterized by prolonged or repeated seizures without full recovery of consciousness between episodes. Traditionally defined as a seizure lasting more than 30 minutes, current guidelines define SE as any seizure lasting more than 5 minutes, or two or more seizures without return to baseline consciousness. It can present in various forms, with convulsive SE (generalized tonic-clonic activity) being the most common and dramatic. Non-convulsive SE is more subtle and requires EEG for diagnosis. Prompt recognition and urgent treatment are essential to prevent permanent brain injury, systemic complications, and death.

Causes

1. Neurological Causes

  • Epilepsy (especially medication non-compliance or withdrawal)

  • Stroke (ischemic or hemorrhagic)

  • Traumatic brain injury

  • Brain tumors

  • Central nervous system infections (e.g., meningitis, encephalitis)

2. Metabolic and Systemic Causes

  • Hypoglycemia or hyperglycemia

  • Hyponatremia or hypernatremia

  • Hypocalcemia, hypomagnesemia

  • Hepatic or renal failure

  • Hypoxia

3. Toxic and Drug-Related Causes

  • Alcohol withdrawal (especially in chronic users)

  • Drug overdose (e.g., theophylline, isoniazid, bupropion, cocaine)

  • Withdrawal from anti-seizure medications

  • Toxic encephalopathy

4. Infections

  • Sepsis

  • CNS infections (e.g., neurocysticercosis, HIV-related CNS disease)

5. Miscellaneous

  • Autoimmune encephalitis

  • Febrile seizures in children (progressing to SE)

  • Eclampsia (in pregnancy)

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Symptoms

1. Convulsive Status Epilepticus (most common)

  • Continuous generalized tonic-clonic seizures lasting >5 minutes

  • Repetitive seizures without regaining consciousness between them

  • Loss of consciousness

  • Muscle rigidity and rhythmic jerking

  • Tongue biting, frothing, urinary incontinence

  • Postictal confusion or coma if seizure stops

2. Non-Convulsive Status Epilepticus

(May require EEG for diagnosis)

  • Altered mental status (confusion, drowsiness, agitation)

  • Minimal or no overt motor activity

  • Twitching of eyelids, facial muscles, or fingers

  • Speech arrest, staring, automatisms

3. Other Signs (Common to Both Types)

  • Autonomic instability:

    • Tachycardia

    • Hypertension or hypotension

    • Hyperthermia

    • Hypoxia

  • Prolonged seizure activity may lead to:

    • Rhabdomyolysis

    • Lactic acidosis

    • Brain injury or coma

Investigations & Lab Results

1. Immediate Bedside Tests

  • Capillary blood glucose: rule out hypoglycemia

  • Pulse oximetry and arterial blood gases (ABG): assess for hypoxia, acidosis

2. Blood Tests

  • Complete blood count (CBC): look for infection or anemia

  • Electrolytes: sodium, potassium, calcium, magnesium (correct imbalances)

  • Renal and liver function tests (RFT, LFT): metabolic or toxic causes

  • Blood glucose: hypoglycemia/hyperglycemia

  • Toxicology screen: drugs, alcohol, poisoning

  • Antiepileptic drug (AED) levels: assess compliance or toxicity

  • Infection markers: CRP, ESR, blood cultures if infection suspected

3. Lumbar Puncture

  • Indications: suspected CNS infection (e.g., meningitis, encephalitis)

  • Analyze for WBCs, glucose, protein, and perform cultures/PCR for viruses

4. Neuroimaging

  • Non-contrast CT brain (initial): rule out hemorrhage, mass, infarct

  • MRI brain (if stable): better for detecting encephalitis, tumors, subtle infarcts

5. Electroencephalogram (EEG)

  • Essential in diagnosing non-convulsive status epilepticus

  • Helps monitor treatment response

  • Continuous EEG monitoring in refractory cases

Complications

1. Neurological Complications

  • Permanent brain injury (especially in refractory SE)

  • Cognitive impairment or memory deficits

  • Cerebral edema

  • Stroke (due to prolonged hypoxia or metabolic derangement)

  • Chronic epilepsy or worsening seizure control

  • Coma or death

2. Systemic Complications

  • Hypoxia and respiratory failure

  • Aspiration pneumonia

  • Cardiac arrhythmias (from metabolic stress or hypoxia)

  • Rhabdomyolysis → acute kidney injury

  • Lactic acidosis and electrolyte imbalances

  • Hyperthermia

  • Hypotension or shock (especially in refractory cases)

3. Treatment-related Complications

  • Sedation-related respiratory depression (due to benzodiazepines or anesthetics)

  • Infection (e.g., from prolonged intubation or catheterization)

  • Hypotension from IV anesthetics (e.g., propofol, phenobarbital)

4. Mortality

  • Mortality rate varies (10–30%), higher in elderly or those with structural brain lesions or delayed treatment

Treatment

-Initial Stabilization (0–5 minutes)

  • Assess and secure airway, breathing, circulation (ABCs)

  • Administer oxygen and place on cardiac monitor

  • Establish IV access

  • Check capillary blood glucose and correct if hypoglycemic (e.g., 50 mL of 50% dextrose IV)

  • Administer thiamine 100 mg IV before glucose if alcohol use or malnutrition is suspected

  • Begin continuous vital sign monitoring

-First-Line Therapy (5–10 minutes)

Benzodiazepines – rapid seizure control

  • IV lorazepam 4 mg at 2 mg/min; may repeat once after 10–15 minutes

  • If no IV access:

    • IM midazolam 10 mg

    • Intranasal or buccal midazolam as alternative

-Second-Line Therapy (10–30 minutes)

Antiepileptic drugs (AEDs) – prevent recurrence

  • IV fosphenytoin 20 mg PE/kg (preferred due to lower risk of arrhythmias)

  • Alternatives:

    • IV phenytoin 20 mg/kg (max 50 mg/min)

    • IV valproic acid 20–40 mg/kg

    • IV levetiracetam 20–60 mg/kg

    • IV phenobarbital 15–20 mg/kg if others not effective

-Refractory Status Epilepticus (>30–60 minutes)

Seizures persist despite adequate benzodiazepine and AED administration

  • Transfer to ICU for continuous monitoring

  • Initiate IV anesthetic agents:

    • Midazolam infusion

    • Propofol infusion

    • Pentobarbital or thiopental (as last-line options)

  • Initiate continuous EEG monitoring

-Additional Management

  • Identify and treat underlying cause (e.g., infection, metabolic imbalance, trauma)

  • Correct electrolyte abnormalities

  • Maintain fluid balance and prevent complications (e.g., rhabdomyolysis, aspiration)

  • Monitor for drug side effects and cardiorespiratory function

Prognosis

Favorable Prognostic Factors

  • Prompt recognition and early treatment (within 5–10 minutes)

  • Young age with no underlying neurological disease

  • Reversible cause (e.g., metabolic, drug-related)

  • Good pre-morbid functional status

  • Short seizure duration

  • Generalized convulsive SE responding to initial therapy

-Poor Prognostic Factors

  • Delay in treatment initiation

  • Elderly patients or those with comorbidities

  • Refractory or super-refractory SE

  • Structural brain lesions (e.g., tumor, stroke, trauma)

  • Hypoxia or systemic complications (e.g., renal failure, sepsis)

  • Non-convulsive SE that goes unrecognized

-Outcomes

  • Mortality Rate:

    • Approximately 10–30% overall

    • Higher in refractory SE and in elderly patients

  • Neurological Sequelae:

    • Cognitive impairment

    • Motor deficits

    • Development of chronic epilepsy

  • Full recovery is possible if treated early, especially in younger patients without comorbidities or brain injury

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