• Treating convulsive SE
• Myoclonic seizures
• Absence seizures
• Nonepileptic psychogenic seizures

Although status epilepticus is defined as seizure activity that lasts for more than 30 minutes or that continues intermittently during this period without recovery of alertness, in practice, a treatment regimen should begin when a seizure lasts for more than a few minutes. The approach discussed here closely follows the recommendations of the Epilepsy Foundation’s Working Group on Status Epilepticus, with a few exceptions.12,45,46 (See Table: Protocol for Treatment of SE)

The initial priority is given to the airway, breathing, and circulation. Oxygen is given by nasal cannula, and the patient is often placed on his or her side to minimize the chance of aspiration. Objects should not be placed in the patient’s mouth. Within the first 5 minutes of a seizure, two reliable IV lines should be established. Venous blood is sent for electrolytes, glucose, and hematology studies and determination of AED levels. If there is any question of hypoglycemia, give 100 mg thiamine followed by 50 mL of 50% glucose by direct push into the IV line.

The pharmacologic approach to status epilepticus begins with treatment with a benzodiazepine, followed by phenytoin and then, if needed, barbiturates for refractory seizures. Lorazepam is preferred because of its longer duration of action, but diazepam is also an acceptable initial treatment. The initial dose can be 2 mg IV of lorazepam, repeated every 5 minutes up to a total dose of 0.1 mg/kg. If the status is stopped, phenytoin loading can then be used to prevent recurrent status.

Phenytoin often controls those seizures not effectively terminated by benzodiazepines. For most adults, the loading dose of 20 mg/kg is sufficient to produce blood levels of 10–15 mg/liter. If the initial dose of phenytoin is not effective, a second dose of 10 mg/kg can be given, which increases the blood level to approximately 25 mg/liter. Phenytoin must be given at a rate no faster than 50 mg per minute in adults, and cardiac monitoring should be used to watch for arrhythmias and hypotension.

Fosphenytoin, a phenytoin prodrug, is preferred when available, as it does not require a glycol diluent that renders phenytoin incompatible with glucose-containing solutions. This compound carries a much lower incidence of thrombophlebitis, can be given at a faster IV rate than phenytoin, and can be loaded intramuscularly when IV access is not available.

Seizures that are refractory to benzodiazepines and adequate doses of phenytoin can be treated with barbiturates. Adequate doses of barbiturates may lead to hypotension and respiratory depression, however, so dopamine should be present at the bedside when therapy with barbiturates is begun, and assisted ventilation should be readily accessible. Phenobarbital is given with an initial loading dose of 20 mg/kg at a rate of no more than 50 mg per minute.

EEG testing is required if the patient does not stop seizing. Continuous EEG is necessary to guide the degree of cerebral electrical suppression. Anesthetic doses of pentobarbital are initiated if the patient remains in status epilepticus (See Table: Pentobarbital-induced anesthesia in refractory generalized tonic-clonic status epilepticus). All patients are intubated before this step, if this has not been done before this time. (Separation of the effects of pentobarbital from the cardiorespiratory complications of refractory generalized tonic-clonic status epilepticus may be difficult.) A loading dose of pentobarbital is 10 mg/kg, which is followed by a continuous infusion at a rate of 0.5 to 4.0 mg/kg per hour. This infusion is titrated to maintain the EEG in a 3-to-1 burst-suppression pattern. (More recent evidence may suggest that titrating therapy to complete suppression of the EEG background may be more effective than titrating to burst suppression.47) When 12 to 24 hours have passed since suppression of epileptiform discharges, the amount of sedation can be lightened with EEG guidance. If seizures recur, a small bolus of pentobarbital is given to return the EEG to burst suppression or complete suppression, and the infusion is continued for another 48 to 60 hours. If seizures recur after this period, the prognosis for meaningful recovery is often poor, although many centers have pursued prolonged drug-induced coma, some for up to 50 days. Surviving patients have significant neurologic impairment.48

Many relatively small studies have tested medications other than pentobarbital for the treatment of refractory status epilepticus, including IV midazolam and propofol infusions.49 In general, these therapies may be useful in certain circumstances (particularly with children53), but their absolute indications have yet to be determined.

Bilateral motor activity with preserved consciousness is rare in epilepsy, with the exception of epileptic myoclonus and supplementary motor seizures. Motor signs may become subtle during prolonged seizures, as the neurons subserving motor function become fatigued and refractory to activation. Animal data suggest that 30 minutes of sustained seizure activity results in irreversible neuronal injury.44

Adapted from: Kolb SJ and Litt B. Management of epilepsy and comorbid disorders in the emergency room and intensive care unit. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;515–535.
With permission from Elsevier (www.elsevier.com).

Reviewed and revised May 2004 by Steven C. Schachter, MD, epilepsy.com Editorial Board.

In patients with a history of myoclonic epilepsy, seizures consist of focal or generalized, rapid, uncontrolled muscle movements that are usually synchronous. Consciousness may or may not be impaired. When these patients present with uncontrolled seizures, the prognosis for full recovery is generally good with proper treatment.15 Usually, they are exquisitely sensitive to treatment with IV benzodiazepines, although the addition of IV valproate preparations is sometimes required.

Postanoxic myoclonus

About 17% of patients who experience hypoxic or ischemic injury that results in coma develop focal, multifocal, or generalized periodic myoclonic movements, often manifested by eye blinking, chewing movements, or multifocal twitching.16 When this type of seizure activity is seen after a global ischemic event, the prognosis for a meaningful recovery is poor. Most experts believe that, with rare exception, this clinical presentation probably represents an agonal neurologic event in an irreparably injured brain rather than an electrical dysfunction in salvageable tissue.

Postanoxic myoclonus is notoriously difficult to control and may be continuous, giving rise to myoclonic status epilepticus. Sometimes paralytic agents are used to eliminate myoclonic movements, but this is not recommended. If the likelihood of survival is poor, it may be done purely for cosmetic reasons, to make the patient’s death easier for the family. In this case, nothing is done to treat the agonal discharges of the dying brain, and electrical status epilepticus persists. Benzodiazepines and other antiepileptic drugs have been used to treat postanoxic myoclonus, but the results are generally poor.

Adapted from: Kolb SJ and Litt B. Management of epilepsy and comorbid disorders in the emergency room and intensive care unit. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;515–535.
With permission from Elsevier (www.elsevier.com).

Reviewed and revised May 2004 by Steven C. Schachter, MD, epilepsy.com Editorial Board.

Occasionally, absence seizures develop in elderly patients with no prior history of seizures.17,18 Patients with this condition appear confused, are variably responsive, and may express automatisms. This state may persist for weeks or months before it is detected.19 It is easy to miss in the emergency department unless one is aware of its presentation. It is usually diagnosed in elderly individuals who are confused, sometimes with a low-grade fever and no other obvious cause of altered sensorium. Diagnosis of this type of absence seizure requires urgent, bedside electroencephalogram (EEG).

Absence seizures in seniors usually respond to low-dose IV benzodiazepines.20,21

Adapted from: Kolb SJ and Litt B. Management of epilepsy and comorbid disorders in the emergency room and intensive care unit. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;515–535. With permission from Elsevier (www.elsevier.com).

Reviewed and revised May 2004 by Steven C. Schachter, MD, epilepsy.com Editorial Board.

Nonepileptic psychogenic seizures (NESs) are episodes of clinical seizurelike activity that do not result from abnormal electrochemical activity in the brain. NESs are potentially life-threatening, owing to iatrogenic morbidity from futile attempts to control the seizurelike activity. About 20% or more of patients with NESs also have epileptic seizures.22,23

Patients with NESs may have a history of psychiatric disease, an unusual medical history, or an atypical response to AEDs. Clinically, they may present with unresponsiveness and minor movements, although sometimes they may present with generalized convulsive movements. Features that sometimes identify NESs include:

• side-to-side head movements
• asynchronous motor movements
• pelvic thrusting
• forced eye closure and guarding the face when presumed to be unresponsive
• alerting to stimuli during convulsive movements

Diagnosis and treatment of this condition are usually beyond the ED setting. Its presentation often results in hospital admission.24

See more information on nonepileptic seizures.

Adapted from: Kolb SJ and Litt B. Management of epilepsy and comorbid disorders in the emergency room and intensive care unit. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;515–535. With permission from Elsevier (www.elsevier.com).

Reviewed and revised May 2004 by Steven C. Schachter, MD, epilepsy.com Editorial Board.