Symptoms and signs

• Status epilepticus is a state of seizure activity lasting for 30 min with no return to consciousness
• A generalised seizure lasting longer than 5 min is highly unlikely to stop spontaneously

Enquire

• Previous diagnosis of epilepsy
• Previous history of status epilepticus
• Recent withdrawal of anti-convulsant drug/missed medication
• Respiratory tract or urinary tract infection
• Vomiting/diarrhoea

Important underlying causes

• Infection
• meningitis
• encephalitis
• abscess
• Acute head injury
• Cerebral tumour
• Metabolic disorders
• renal failure
• hypoglycaemia
• hypercalcaemia
• Drug overdosage
• tricyclics
• phenothiazines
• theophylline
• isoniazid
• cocaine
• Acute cerebral infarction
• Alcohol intoxication/withdrawal
• Anoxic encephalopathy

Investigations

• Capillary blood glucose
• Venous blood glucose
• FBC, U&E, Calcium
• If patient has history of seizures check serum anticonvulsant concentration ONLY if there are clinical symptoms and/or signs of toxicity, suspicion of non-compliance or the patient is pregnant
• If new onset epilepsy, CT scan to exclude space-occupying lesion

Differential diagnosis

• Non-epileptic attack disorders (pseudo-seizures)

• Treat without delay
• generalised tonic-clonic status is potentially life-threatening
• Do not attempt to put anything into patient’s mouth during a seizure, even if tongue injured
• Intubation, if necessary, requires special care
• Avoid rolling patient during a seizure unless absolutely necessary as this can cause injury to shoulder/hip joints

0-5 min

Watch and support

• Watch and assess (epileptic seizure, syncope, non-epileptic attack)
• Assess secondary metabolic factors (hypoglycaemia, electrolyte imbalance, lactic acidosis, dehydration, hyperpyrexia)
• Protect airway and support respiration if possible
• if there is any period of relaxation, try carefully to insert an airway
• Oxygen (high flow mask) 10 L/min

IV access

• Blood test - glucose, U&E, calcium, FBC
• if patient taking anticonvulsant drug, check serum anticonvulsant. See Therapeutic drug monitoring guideline
• Lorazepam 4 mg IV (diluted 1:1 with sodium chloride 0.9% or water for injection) as single slow bolus injection into large vein
• if lorazepam unavailable, give diazepam (Diazemuls^®) 10 mg IV over 2 min (prolonged sedative effect)
• monitor oxygen saturation carefully for evidence of respiratory depression
• If poor nutrition/alcoholism, give parenteral thiamine as Pabrinex IV High potency injection 2 pairs of ampoules (mixed) by IV infusion in sodium chloride 0.9% 100 mL over 30 min 8-hrly
• If hypoglycaemia suspected, give glucose 20% 100 mL or glucose 10% 200 mL IV over 15 min into a large vein (care is required as these concentrations are irritant)

5-10 min

• Call neurology SpR
• Repeat lorazepam 4 mg IV if necessary (diluted 1:1 with sodium chloride 0.9% or water for injection); as a single bolus injection into a large vein
• do not exceed total dose of 8 mg of lorazepam
• if lorazepam unavailable, give diazepam (Diazemuls^®) 10 mg IV slowly over 2 min repeated, if necessary, after a further 5 min
• do not exceed total dose of 20 mg of diazepam
• Monitor oxygen saturation carefully for evidence of respiratory depression

10-30 min

Seizures continue after 10 min

• If patient not already taking maintenance phenytoin therapy, give phenytoin IV with cardiac monitoring unless contraindicated. See Phenytoin IV guideline
  • If phenytoin contraindicated, give levetiracetam IV. See Levetiracetam IV guideline
• If already taking maintenance phenytoin therapy, contact neurology SpR to discuss reduced dose of IV phenytoin, or use of levetiracetam. See Levetiracetam IV guideline
• Check blood gases
• If, at any stage, respiratory depression or cardiac arrhythmia is apparent or pH <7.0, contact critical care
• If still unconscious after 15 min and hypoglycaemia confirmed, repeat glucose 20% 100 mL or glucose 10% 200 mL IV over 15 min

30 minutes

Satisfactory control still not established after 30 min

• If neurology junior staff are in attendance, contact SpR or consultant for advice and arrange transfer to critical care
• Further specialised management in critical care area

Reasons for failure to respond

• Incorrect diagnosis
• Underlying cause (e.g. metabolic abnormalities) not recognised and treated
• Delay in intubation and anaesthesia
• Inappropriate use of drugs/dosage
• Delay in initiating maintenance anticonvulsant therapy

• All patients should now be under the care of the neurology team

Not improving

• Reconsider underlying causes
• If patient transferred to critical care and anaesthetised, arrange EEG as soon as possible after intubation to establish state of cerebral ictal activity
• If continued sedation necessary, repeat EEG 24-hrly

Improving

• Once seizure activity has ceased, place patient in recovery position
• In patients with previously diagnosed epilepsy, recommence previous AED therapy
• In newly diagnosed patients, neurologist to introduce appropriate therapy before discharge
• Continue oxygen as required. See Hypoxaemia guideline

• Discharge when patient seizure-free for 48 hr and fit to leave hospital, and anti-convulsant drug therapy established
• Review existing follow-up appointments for patients with a previous history of epilepsy
• Ensure patients with no previous history have review appointment arranged
• Refer all cases to clinical nurse specialist before discharge if not already seen during admission