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.
- 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.
- 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.
- 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
- 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.
- Impaired consciousness, ranging from lethargy to coma
- Disorientation (after GCSE controlled)
- Pain associated with injuries, for example:
- Shoulder dislocations
- Head and facial trauma
- Early signs
- Generalized convulsions
- Acute injuries or CNS insults that cause extensor or flexor
- Hypothermia or fever suggesting intercurrent illnesses (e.g.,
sepsis or meningitis)
- Normal blood pressure or hypotension
- Respiratory compromise
- Late signs
- Clinical seizures may or may not
- Pulmonary edema with respiratory failure
- Cardiac failure (dysrhythmias, arrest, or cardiogenic shock)
- Hypotension or hypertension
- Disseminated intravascular coagulation or multiorgan failure
- Complete blood count (CBC) with differential
- Serum creatinine
- Urine drug/alcohol screen
- Blood cultures
- Arterial blood gases to assess for metabolic and respiratory
- Serum drug concentrations if previous anticonvulsant use
- Computed tomography (CT) with and without contrast
- Magnetic resonance imaging (MRI)
- Radiograph if indicated to diagnose fractures
- Lumbar puncture if central nervous system (CNS) infection
- Obtain electroencephalograph immediately and after seizures
- Seizure due to:
- Electrolyte abnormality
- Alcohol withdrawal
- Bacterial meningitis
- Herpes encephalitis
- Brain tumor
- CNS vasculitis
- Cardiac arrhythmia
- Brainstem ischemia
- Panic attack
- Terminate clinical and electrical seizure activity.
- Minimize side effects.
- Prevent recurrent seizures.
- Avoid neurologic sequelae.
- Algorithm for treatment of GCSE in Figure 1.
- Begin treatment of GCSE during diagnostic workup for any tonic-clonic
seizure that does not ...