17B. Status epilepticus
Status epilepticus is defined as either a single epileptic seizure lasting longer than 5 minutes, or more than one seizure without recovery of consciousness in-between. It’s more commonly a result of symptomatic seizure rather than epilepsy.
It’s a life-threatening condition with high mortality, as cerebral oedema, aspiration, shock, rhabdomyolysis, etc. may occur.
The definition used to be 30 minutes, but because we recognised that the longer the seizure lasts, the worse the prognosis and the harder it is to stop it, we now have a much more aggressive approach; we no longer wait longer than a few minutes before treating.
Treatment
- 0th step: Ensure stability and free airways (ABC)
- 1st step: 1 dose BZD
- 10 mg midazolam i.m. or 10 – 20 mg diazepam i.v. or 4 mg lorazepam i.v.
- Alternative: buccal or rectal midazolam
- 2nd step: If no response within 1 minute -> give another dose of BZD
- 3nd step: If no resolution after 2 doses of BZD -> give antiepileptic
- Give IV loading dose followed by continuous infusion of an antiepileptic, like valproate, fosphenytoin, or levetiracetam
- 4nd step: If no resolution after antiepileptic -> give general anaesthesia
- With propofol or midazolam infusion
Midazolam has a short duration of action, and so lorazepam or diazepam, which last longer, is often preferred.
If the status remains after 2 doses of BZD the condition is called refractory or established status epilepticus.