ACUTE SEIZURES AND STATUS EPILEPTICUS

Status epilepticus = duration > 30 min or seizures recurring prior to recovery from the post-ictal state

BUT

Generalised seizure = seizure activity with LOC (e.g. tonic-clonic, absence)

Partial seizure = seizure activity without LOC (e.g. TLE)

GENERAL MANAGEMENT

DRUG TREATMENT

Use drugs in progressive order if seizure is not controlled:

  1. Midazolam 0.1mg/kg IV or 0.15mg/kg IM

OR

Diazepam 0.2mg/kg IV or 0.5mg/kg PR

(Clonazepam 0.01mg/kg IV may be better for partial seizures)

  1. Phenytoin 20mg/kg IV (< 0.5mg/kg/min)
  1. Phenobarbitone 20mg/kg IV (1mg/kg/min)
  1. Thiopentone 3-5mg/kg

AND

  1. Midazolam 0.75-10 mcg/kg/min

OR

Propofol 2-10mg/kg/hr

OR

Thiopentone 1-3mg/kg/hr

Parlysed patient require continuous EEG monitoring to assess for ongoing seizure activity (supressing motor activity is not enough!)

COMPLICATIONS

 

SPECIAL SITUATIONS

Hypoglycaemia - 50ml 50% dextrose

Hyponatraemia - 3% NaCl 10ml/kg (over 60min)

Hypernatraemia - 5% dextrose (correct over 48 hrs)

Hypocalcaemia - CaGluc 10% 0.5ml/kg then 5-8ml/kg/24hrs

Hypomagnesaemia - MgSO4 10% 0.02-0.05ml/kg 6/24

Alcohol withdrawal - benzodiazepines

Cocaine - benzodiazepine, antihypertensives

Tricyclic antidepressants - diazepam, sodium bicarbonate 50-150 mmol (until pH 7.55), thiopentone

Anticholinegics - Physostimine 1-2g/10min

Isoniazid (INH) - Pyridoxine 5g/50ml (over 3min) or 1mg/mg of INH ingested

Theophylline - benzodiazepine, thiopentone, +/- charcoal haemoperfusion

Eclampsia - benzodiazepine, MgSO4 15-25 mmol (over 20min) until serum Mg+ 2-4mmol/L then 5-10mmol/hr

DRUG & SIDE EFFECTS

Most cause

Phenytoin can cause arrhythmias (due to its cogener) but not respiratory depression