Status Epilepticus

Status epilepticus is generally defined as more than 30 minutes of unconsciousness and continuous or intermittent, generalized seizure activity. However, because most seizures last 2 minutes or less, any seizure longer than 5 minutes may progress to status epilepticus. Patients with recurrent seizures without recovery to wakefulness should also be considered to be in status epilepticus. Status epilepticus can be alarming to observe, even for experienced clinicians. A systematic approach to patients in status epilepticus can facilitate optimal patient care during such an episode. The first step in the management of patients with status epilepticus is to support vital functions. The airway should be protected. Although the patient should be intubated if necessary, this usually requires neuromuscular blockade, and bag and mask ventilation is often preferable. The patient's vital signs should be closely monitored, including continuous oxime-try and ECG. Supplemental oxygen at a rate of about 4 L/min is recommended. Intravenous access should be secured for the administration of parenteral medications and blood drawn for a CBC, toxicology screen, and determination of electrolyte, glucose, calcium, magnesium, and anticonvul-sant drug levels. The patient should receive thiamine, 100 mg IV, followed by 50 mL of D50W.

If the patient continues to seize, parenteral agents may be given, including lorazepam, 0.1 mg/kg IV at 2 mg/min, or diazepam, 0.2 mg/kg (max 10 mg) at a maximum rate of 5 mg/min. These agents have a relatively rapid onset and short duration of action. Simultaneous loading with phe-nytoin is therefore recommended. Phenytoin is loaded at 20 mg/kg IV at a rate of less than 50 mg/min through a line infusing glucose-free saline, to avoid precipitation of phe-nytoin in the line. Fosphenytoin (Cerebyx) is the prodrug of phenytoin and has a more favorable safety profile compared with phenytoin, can be given at a faster rate (150 mg/min), and converts to phenytoin after first-pass metabolism, but it is more costly than phenytoin. Blood pressure and cardiac rhythm must be closely observed because of the ability of phenytoin to precipitate hypotension and heart block. If these side effects appear, they often resolve when the rate of administration is decreased. If seizures continue despite these measures, phenobarbital may be administered parenterally. As a last resort, barbiturate coma or general anesthesia can be instituted. Propofol (Diprivan) and midazolam (Versed) administered as continuous IV drips are often used in neu-rocritical care settings to induce coma for status epilepticus.

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