Makindo Medical Notes

• 0-5 mins: Recovery position, observe, administer oxygen. Check ABCs and blood glucose.
• If the seizure has settled within 5 minutes, continue to observe and manage as usual.

General Considerations for Seizures Lasting < 5 mins

• Assess for history of known epilepsy, recent medication changes, drug/alcohol use, or withdrawal.
• Ensure ABCs, provide oxygen, check glucose. Place the patient in the recovery position, and consider a nasopharyngeal airway if needed.
• Monitor vital signs: temperature, heart rate, blood pressure, and oxygen saturation.
• If Glasgow Coma Scale (GCS) is < 9, request an anaesthetic review for potential intubation.
• Establish IV access and send blood samples for FBC, U&E, LFT, calcium, glucose, and anticonvulsant levels.
• Treat hypoglycaemia with 100 ml of 10% glucose or 1 mg of IM glucagon if IV access is not available.
• If the patient has a history of alcohol use, malnutrition, or hyperemesis, administer IV Pabrinex (2 pairs over 10 mins).

Time > 5 mins: Administer a Benzodiazepine

• First-line choices for benzodiazepine administration:
  • Lorazepam 4 mg (0.1 mg/kg) slow IV
  • Midazolam 10 mg buccal or IM
  • Diazepam 10 mg rectal
  • Pregnancy (Eclampsia): Magnesium sulfate 4 g IV bolus
• Monitor for respiratory depression and manage as needed.

Time > 10-20 mins: Repeat Benzodiazepine Dose

• If the seizure continues after 10-20 mins, consider repeating the benzodiazepine dose (do not exceed two doses).
  • Lorazepam 4 mg IV
  • Midazolam 10 mg buccal or IM
  • Diazepam 10 mg rectal
• Continue monitoring ABCs and manage respiratory depression if it occurs.

Time > 20 mins: Consider Second-Line Anticonvulsants, Prepare for ICU

• If the seizure persists for > 20 mins:
  • IV Levetiracetam 60 mg/kg (max 4500 mg) in 100 ml NS over 10 minutes
  • IV Phenytoin 20 mg/kg (max 2000 mg) at 50 mg/min (25 mg/min in the elderly or those with cardiac conditions); use a cardiac monitor.
  • IV Valproate 40 mg/kg (max 3000 mg) in 100 ml NS over 5 minutes. Avoid in pregnancy, mitochondrial disease, or advanced liver disease.
• Alert HDU/ITU for potential transfer and advanced management.

Time > 30 mins: Consider Third-Line Treatment, Prepare for Intubation

• If the seizure continues beyond 30 minutes, involve the ITU team. Consider:
  • IV Propofol, Midazolam, or Thiopental sodium for sedation and seizure control.
  • Continuous EEG monitoring for non-convulsive status epilepticus.
• Investigate potential causes such as CNS infections:
  • If HSV encephalitis is suspected, start IV Aciclovir 10 mg/kg 8-hourly.
  • For suspected bacterial meningitis, consider IV Cefotaxime.
• Consider IV Dexamethasone 10 mg if cerebral oedema is suspected and infection is excluded.
• Manage increased intracranial pressure (ICP) with IV Mannitol if coning is suspected.

Post-Stabilization Management

• Consider brain imaging (CT/MRI) and lumbar puncture once the patient is stable.
• If encephalitis is suspected, continue appropriate antiviral therapy.
• Consider long-term management with anticonvulsants and refer to neurology for follow-up.

Common Causes of Status Epilepticus

• Known Epilepsy: Missed medication doses, alcohol, drug withdrawal, infections, or stress.
• New-Onset Seizures: Brain injury, stroke, tumour, infections (meningitis, encephalitis), metabolic derangements (hypoglycaemia, hyponatraemia), or drug/toxin exposure.
• Non-Epileptic Mimics: Psychogenic non-epileptic seizures, syncope, or metabolic disturbances.

Complications of Status Epilepticus

• Injuries: Fractures, lacerations, or tongue biting.
• Aspiration pneumonia and respiratory failure.
• Hypoxic brain injury from prolonged seizures.
• Non-convulsive status (confirmed with EEG).
• Venous thromboembolism due to immobility.

Investigations

• FBC, U&E, CRP, calcium, magnesium, and glucose.
• CT head, lumbar puncture, or EEG if clinically indicated.
• Check anticonvulsant drug levels if the patient is on maintenance therapy.
• Perform a toxicology screen for potential drug exposure.

References

• NICE Protocols for Treating Convulsive Status Epilepticus
• The Walton Centre Status Epilepticus Guidelines