•If available, continuous EEG monitoring should be performed.

•Pharmacologic coma should be maintained for 12 h after the last seizure, with EEG goal of attaining burst suppression, after which gradually taper off infusion of the anesthetic agent every 3 h with EEG monitoring, and if there are no clinical or electrographic seizures, then discontinue the infusion.

•Continue EEG monitoring for at least 24 h after end of infusion.

•If clinical or electrographic seizures recur, reinstitute coma therapy with the same anesthetic agent to which the seizures were responsive.

•Make another attempt after 24 h of seizure freedom.

•Look for complications and manage hypotension, bradycardia, pulmonary edema, nosocomial sepsis, ileus, venous thromboemboli, skin breakdown, and exposure keratitis.

Step 6: Initiate maintenance treatment (Table 28.2)

•In parallel with emergency treatment, attention must be given to maintain antiepileptic drug (AED) therapy to prevent recurrence of seizures in close consultation with the neurologist.

•In patients known to have epilepsy, their usual AEDs should be maintained and dose adjustments should be made depending on AED levels.

•In patients presenting de novo, the AEDs, phenytoin/fosphenytoin, or valproic acid used to control the status can in principle be continued as oral maintenance therapy.

•In others, unless relatively short-lived treatment is anticipated, the preference is to initiate oral maintenance therapy with valproic acid or carbamazepine or any of the newer AEDs, topiramate or levetiracetam.

•Duration of antiepileptic is variable, depending on reversibility of underlying etiology, and should be decided with neurology consultation.

Step 7: Identify and manage the nonconvulsive status

•The nonconvulsive status may present as unexplained coma and fluctuating level of consciousness and is diagnosed by seizure activities in EEG monitoring.

•No concurrent motor activity is usually noticed.

•IV benzodiazepines—lorazepam or diazepam—are the drugs of choice.

•Allow 5 min to determine whether seizures terminate; if there is no response, repeat benzodiazepines once.

•If EEG monitoring still shows continuous electrographic seizures, consider valproic acid in case of absence type of nonconvulsive status epilepticus and consider phenytoin/fosphenytoin or valproic acid in case of other types of nonconvulsive status epilepticus the alternative option, particularly in the elderly will be intravenous levetiracetam.

Suggested Reading

1.Millikan D, Rice B, Silbergleit R. Emergency treatment of status epilepticus: current thinking. Emerg Med Clin North Am. 2009;27(1):101–13.

Current thinking about the acute treatment of status epilepticus (SE) emphasizes a more aggressive clinical approach to this common life-threatening neurologic emergency. In this review, the authors consider four concepts that can accelerate effective treatment of SE. These include (1) updating the definition of SE to make it more clinically relevant, (2) consideration of faster ways to initiate first-line benzodiazepine therapy in the prehospital environment, (3) moving to sec- ond-line agents more quickly in refractory status in the emergency department, and (4) increasing detection and treatment of unrecognized nonconvulsive SE in comatose neurologic emergency patients.

2.Meierkord H, Holtkamp M. Non-convulsive status epilepticus in adults: clinical forms and treatment. Lancet Neurol. 2007;6:329–39.

An excellent review on nonconvulsive status epilepticus.

3.Bassin S, Smith TL, Bleck TP. Clinical review: status epilepticus. Crit Care. 2002;6(2): 137–42.

This review discusses current definitions of SE, as well as its clinical presentation and classification. The recent literature on epidemiology is reviewed, including morbidity and mortality data. An overview of the systemic pathophysiologic effects of SE is presented. Finally, significant studies on the treatment of acute SE and refractory SE are reviewed, including the use of anticonvulsants, such as benzodiazepines and other drugs.

4.Claassen J, Hirsch LJ, Emerson RC, et al. Treatment of refractory status epilepticus with pentobarbital, propofol, or midazolam: a systematic review. Epilepsia. 2002;41:146–53.

Treatment with pentobarbitone, or any cIV-AED infusion to attain EEG background suppression, may be more effective than other strategies for treating RSE. However, these interventions were also associated with an increased frequency of hypotension, and no effect on mortality was seen.

5.Treiman DM, Meyers PF, Walton NY. A comparison of four treatments for generalized convulsive status epilepticus: Veterans Affairs Status Epilepticus Cooperative Study Group. N Engl J Med. 1998;339:792–8.

As initial intravenous treatment for overt generalized convulsive status epilepticus, lorazepam is more effective than phenytoin. Although lorazepam is no more efficacious than phenobarbital or diazepam plus phenytoin, it is easier to use.