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Source: Phelps SJ, Hovinga CA, Wheless JW. Status Epilepticus. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7985805. Accessed June 8, 2012.

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  • Seizure lasting longer than 30 minutes regardless of whether consciousness is impaired; or recurrent seizures without intervening period of consciousness between seizures.
  • Generalized convulsive status epilepticus (GCSE) is most common and severe form.

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  • Most episodes in known epileptics occur because of:
    • Acute anticonvulsant withdrawal
    • Metabolic disorder or concurrent illness
    • Progression of preexisting neurologic disease
  • Other common precipitating events in adults:
    • Cerebrovascular disease
    • Low anticonvulsant serum concentrations
  • Some prescription, over-the-counter, and recreational drugs can cause new-onset GCSE.
  • Elevated serum anticonvulsant concentration or rapid anticonvulsant withdrawal can also precipitate GCSE.

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  • Phase I: Each seizure increases plasma epinephrine, norepinephrine, and steroid concentrations that may cause hypertension, tachycardia, and cardiac arrhythmias. Muscle contractions and hypoxia cause acidosis, hypotension, shock, rhabdomyolysis, and secondary hyperkalemia.
  • Phase II: Begins 30 minutes into seizure with hypotension, compromised cerebral blood flow, normal or low serum glucose; hyperthermia, respiratory deterioration, hypoxia, and ventilatory failure may develop.

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  • US incidence 100,000–152,000 cases/year; worldwide incidence 1.2–5 million cases/year.
  • No predilection for gender or socioeconomic status.
  • Occurs more frequently in nonwhites across all ages.
  • Most episodes occur in individuals with no history of epilepsy, but 5% of adults and 10–25% of children with epilepsy develop GCSE.

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Signs and Symptoms

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  • Impaired consciousness, ranging from lethargy to coma
  • Disorientation (after GCSE controlled)
  • Pain associated with injuries, for example:
    • Tongue lacerations
    • Shoulder dislocations
    • Head and facial trauma
  • Early signs
    • Generalized convulsions
    • Acute injuries or CNS insults that cause extensor or flexor posturing
    • Hypothermia or fever suggesting intercurrent illnesses (e.g., sepsis or meningitis)
    • Incontinence
    • Normal blood pressure or hypotension
    • Respiratory compromise
  • Late signs
    • Clinical seizures may or may not be apparent.
    • Pulmonary edema with respiratory failure
    • Cardiac failure (dysrhythmias, arrest, or cardiogenic shock)
    • Hypotension or hypertension
    • Disseminated intravascular coagulation or multiorgan failure
    • Rhabdomyolysis
    • Hyperpyremia

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Laboratory Tests

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  • Complete blood count (CBC) with differential
    • Serum chemistry profile
    • Electrolytes
    • Calcium
    • Magnesium
    • Glucose
    • Serum creatinine
    • ALT
    • AST
  • Urine drug/alcohol screen
  • Blood cultures
  • Arterial blood gases to assess for metabolic and respiratory acidosis
  • Serum drug concentrations if previous anticonvulsant use

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Imaging

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  • Computed tomography (CT) with and without contrast
  • Magnetic resonance imaging (MRI)
  • Radiograph if indicated to diagnose fractures

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Diagnostic Procedures

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  • Lumbar puncture if central nervous system (CNS) infection suspected
  • Obtain electroencephalograph immediately and after seizures controlled.
  • Electrocardiogram

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Differential Diagnosis

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  • Seizure due to:
    • Hypoglycemia
    • Electrolyte abnormality
    • Alcohol withdrawal
    • Cocaine
    • Bacterial meningitis
    • Herpes encephalitis
    • Brain tumor
    • CNS vasculitis
  • Syncope
  • Cardiac arrhythmia
  • Brainstem ischemia
  • Pseudoseizure
  • Panic attack
  • Migraine

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  • Terminate clinical and electrical seizure activity.
  • Minimize side effects.
  • Prevent recurrent seizures.
  • Avoid neurologic sequelae.

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  • Algorithm for treatment of GCSE in Figure 1.
  • Begin treatment of GCSE during diagnostic workup for any tonic-clonic seizure that does not ...

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