(1)
(2)
IF HYPOGLYCAEMIC (Glucose < 4 mmol/L )
Give 150-200ml 10% glucose IV over 15mins (i.e. 600ml/Hr)
If seizures continue, repeat step 1 AND commence 10% glucose
infusion at 100ml/Hr.
*If suspicion of alcohol excess or malnutrition give 1x pair IV Pabrinex with IV
glucose replacement
STATUS EPILEPTICUS – 5 minutes
≥ 5 minutes continuous generalised seizure activity or
≥ 5 minutes recurrent generalised seizures without recovery
1st Line treatment - IV Access
Lorazepam 4mg IV bolus or
Diazepam 10mg IV bolus
MONITOR FOR 5 MINUTES - If status
continues at 5 minutes repeat dose
CONSIDER IN ALL PATIENTS
Collateral History / PPM+ record:
• Identify if known epilepsy +/- seizure care plan
• Medication history (see GP Tab on PPM+)
1st Line treatment - No IV Access
Midazolam 10 mg Buccal / IM or
Diazepam 10mg PR
MONITOR FOR 5 MINUTES - If status
continues at 5 minutes repeat dose
ESTABLISHED STATUS EPILEPTICUS – 15 minutes
Call 2222 - Escalate to ICU / Anaesthetics
Consider aetiology of seizure +/- management of cause:
• Drug intoxication or withdrawal (including alcohol)
• AED issues (poor compliance, poor absorption, recent AED changes,
medication interactions or sub therapeutic levels)
• Infection (Sepsis / CNS infection)
• Metabolic disturbance (electrolytes, glucose)
• CNS pathology (tumour, stroke, encephalitis, PRES,
neurodegenerative diseases etc.)
Consider PNES (Psychogenic non-epileptic seizure) / NEAD (Nonepileptic attack disorder): If doubt discuss with neurology but continue
pathway. Do not use lactate as sole marker of epilepsy vs. NEAD.
Ensure IV or IO access established to begin 2nd line treatment as below
Benzodiazepine dosing for low body weight (<40Kg): Lorazepam = 0.1 mg/kg,
maximum 4 mg. Diazepam = 0.2 mg/ kg, maximum 10 mg
2nd Line treatment – AED Loading at 15 minutes
Loading with one of the following IV anti-epileptic drugs (AEDs):
IV Levetiracetam 60mg/kg, maximum 4500mg - In 100ml sodium chloride 0.9% over 10
minutes
IV Phenytoin 20mg/kg, maximum 2000mg - Give undiluted. Rate 50mg/min or 25mg/min
for elderly or cardiac history. An in-line filter (0.22 microns) should be used. ALWAYS INFUSE
WITH ECG MONITORING. Additional information on loading see link: leedsformulary.nhs.uk
IV Valproate 40mg/kg, maximum 3000mg - In 100ml sodium chloride 0.9% over 5 minutes.
AVOID IN WOMEN OF CHILDBEARING AGE IF POSSIBLE
ONGOING STATUS EPILEPTICUS DESPITE 2nd LINE
THERAPY < 30 minutes
Commence additional IV AED from above list
If no AED suitable from list call neurology registrar
At ≥ 30 minutes
move to refractory
status algorithm
Considerations for AED choice
Levetiracetam
Established
SE
15-30 mins
INITIAL INVESTIGATIONS
FBC, U&Es, LFTs, Ca2+, Mg2+, clotting studies, VBG, Glucose
If applicable: bloods for AED levels, B-HCG, Toxicology screen
If no known seizure history or overt trigger: consider neuroimaging
•
•
•
Avoid if: Behaviour or mood disorder, renal impairment (see BNF),
using brivaracetam
Preferred for: Women of childbearing age, polypharmacy (relatively few
drug-drug interactions)
Phenytoin
Early SE
5-15 mins
START TIMER - INTITAL SEIZURE MANAGEMENT
Assess - Airway / Breathing / Circulation
Start high flow O2
Position patient to prevent aspiration and ensure safety
Establish IV access
Capillary blood glucose check
Monitor vital signs: SpO2 / HR / BP / ECG
Needs ECG monitoring Risk of arrhythmia.
Avoid if: Known or suspected generalised / genetic epilepsy. Low BP /
HR. Heart block. Porphyria. Overdose of recreational drugs. Alcohol
withdrawal.
Valproate
Generalised
Seizure
0-5 mins
Avoid if: woman of childbearing age, metabolic/mitochondrial disease
(suspected or known), liver failure, pancreatitis, use of carbapenem
Preferred for: known or suspected generalised / genetic epilepsy,. Comorbid mood disorder / migraines
Alternative AEDs to be considered with neurology discussion only – Lacosamide or
Phenobarbital – See Page 3 for details
Refractory
SE
30+ mins
REFRACTORY STATUS EPILEPTICUS (RSE)
Generalised seizures of >30 minutes duration despite 2 doses of benzodiazepine and at
least 1 dose of AED.
THERAPEUTIC TARGET
Burst suppression with no breakthrough seizures (clinical or EEG) for 24 48 hours
Manage only in appropriate setting with anaesthetics / ICU input for airway support.
These treatments are only to be delivered by clinicians experienced in their use.
3rd line treatment - General Anaesthetic
1) INDUCTION - Propofol, midazolam, thiopentone or ketamine
2) MAINTENANCE - Continuous infusion of propofol and/or midazolam.
3) CONTINUE AEDs - Ensure newly loaded AEDs and pre-hospital AEDs prescribed on eMEDs
•
•
•
•
•
•
EARLY CONSIDERATIONS
Consider neuroimaging
Correct any metabolic derangement
Female patients – Ensure pregnancy / eclampsia excluded
Continuous EEG / bispectral index (BIS) monitoring, or regular EEGs
Ensure on adequate antiepileptic medication / AED level checked
Ensure NOK informed and aware of treatment decisions / prognosis
Check AED levels
Consider anaesthetic agent bolus – Propofol or Midazolam
Consider starting additional IV AED – Discuss with neurology on-call if required
Midazolam
Failure of seizure control after 1 hour
Propofol
Anaesthetic agent doses
Bolus: 1-2mg/kg
Maintenance:
0.5-4mg/kg/hour
Bolus: 0.2mg/kg
Maintenance:
0.1mg/kg/hour
Considerations for agents choice
Monitor for propofol infusion syndrome
(PRIS) – ECG, CK, lipid profile, renal function,
oedema. PRIS risk increases with dose.
Midazolam interacts with multiple drugs
including AEDS. Can accumulate in renal
failure and obese patients. Tachyphylaxis
with prolonged use.
Seek specialist neurology input.
Ensure AEDs and anaesthetic agent doses are optimised.
•
•
•
•
Neuroimaging
CSF / Serum: auto-immune
encephalitis antibody panel, exclude
occult infection
Toxicology screen: illicit drugs and
medications which can potentiate
seizures
Consider paraneoplastic aetiology: CTTAP, testicular ultrasound / pelvic
ultrasound, breast imaging
•
•
•
•
•
•
•
•
Magnesium infusion
Alternative AEDs: NG topiramate, IV
lacosamide, IV phenobarbital.
Immunomodulation (e.g. high dose
steroids, IV immunoglobulin , plasma
exchange, rituximab)
Neurosurgical intervention
Ketogenic diet (ICU dietitian discussion)
Hypothermia
Pyridoxine
Electrical and magnetic brain
stimulation strategies
Ketamine
Very long half life. Prone to accumulation
due to zero order kinetics.
Maintenance:
5mg/kg/hour
Slow administration. Can suppress brain
stem reflexes. Can suppress immune
system. Slows gut motility.
Maintenance:
1-4mg/kg/hour
Bolus: 3mg/Kg
Treatment options to consider:
Consider aetiology / investigations:
Thiopental
SUPER REFRACTORY STATUS EPILEPTICUS (SRSE)
Generalised convulsive seizures 24 hours after induction with general anaesthesia.
Bolus: 15 mg/Kg (Max.
100mg) at 50-100mg/min
via pump
Magnesium
Super
Refractory
SE
>24H
Bolus: 3-5mg/Kg
Phenobarbital
On-going failure of seizure control
Consider infusion with additional anaesthetic agent - see listed agents in grey
Liaise with neurology team
Liaise with pharmacist
Can impair EEG / BIS monitoring.
Starting maintenance: 1
mg/kg/hour (see titration
in full guidelinetext)
Loading: 4g over 15 min
Maintenance: 1g / hour
to target serum level >3.5
mmol/L
Caution in cardiac conduction block, low BP,
myasthenia, muscle blocking agents.
Monitor serum Mg2+ levels and deep tendon
reflexes. Slow rate if bradycardia occurs.
Treatment of SRSE should be guided by neuro-intensive care, neurology,
neurophysiology and pharmacy in an MDT approach.
The management of SRSE does not currently have high quality
randomised controlled trial evidence. Treatments should be reviewed
regularly and if considered to be ineffective they should be ceased to
minimise risk of adverse effects.
AED maintenance doses
INFORM NEUROLOGY
Refer to neurology via Patient Pass
Patients not known to have epilepsy will need ‘First Fit Clinic’ follow up
Phenobarbital
Lacosamide
CONSIDER WHERE TO MANAGE PATIENTS POST STATUS
Patients need to be in an environment where they can be observed easily
Discuss location with SpR / consultant in charge of patient’s care
Commence a ‘Seizure Record’ on PPM+ (under clinical documents)
Continue to monitor regularly for further seizure activity over next 24H
If slow to recover GCS, consider:
• Underlying pathology causing status (e.g. low glucose, alcoholic
encephalopathy, illicit drug use, sepsis, stroke, cerebral bleed, CNS
infection )
• Benzodiazepine or AED side effect
• Non-convulsive status epilepticus (especially in elderly - discuss with
neurology +/- arrange urgent EEG )
Levetiracetam
ENSURE NEWLY LOADED AEDs CONTINED
Prescribe maintenance doses of loaded antiepileptic drugs on eMEDs
See table in right hand side column for dosing
If using phenytoin, ensure drug level prior to next dose
PATIENTS WHO CLINICALLY REMAIN LOW GCS OR CONFUSED POST
STATUS DESPITE RESOLUTION OF GENERALISED SEIZURE ACTIVITY
Commonly post-ictal state – monitor for recovery
Phenytoin
IMMEDIATE MANAGEMENT AFTER STATUS EPILEPTICUS
Reassess - Airway / Breathing / Circulation
Assess GCS - If remains low consider causes (see box to right)
Assess for focal neurology
Consider aetiology of seizure
In known epilepsy consider triggers
Valproate
Patient
care after
SE
Commence after 12 hours - 1000mg BD
(IV to PO conversion = 1:1)
In renal impairment eGFR
<50 review doses with BNF.
If dialysis patient, consult
renal pharmacist.
Commence after 6 hours – 100mg TDS
(IV to PO tablets or capsules conversion =
1:1).
If switching to oral liquid,
convert dose using formula:
100mg phenytoin sodium
(IV or tablet) = 90mg
phenytoin base (oral liquid
solution).
Check serum albumin and serum
phenytoin before next dosing as per “LTHT
Intravenous Phenytoin for Status
Epilepticus in Adults guideline” - Access
via http://www.leedsformulary.nhs.uk
Commence after 12 hours – 1000mg BD
(IV to PO conversion = 1:1)
Avoid in liver impairment
Commence after 12 hours – 100mg BD
(IV to PO conversion = 1:1)
Dose reduction in renal and
hepatic impairment –
discuss with pharmacy .
Only for use with neurology discussion
Discuss with neurology for dosing
Only for use with neurology discussion
Alternative AEDs loading regimens - NEUROLOGY OR NEURO-ICU APPROVAL ONLY
Lacosamide
• IV Loading dose: 200mg
• Dilute in 50-100mL of 0.9% sodium cholride or glucose 5%.
• Infuse over 15 minutes
Phenobarbital
•
IV Loading dose: 15 mg/kg
•
Dilute each 1mL ampoules to at least 10mL sodium chloride 0.9% or glucose 5%. Use a 100mL bag for higher injection volumes.
•
Infuse at a rate of 100 mg/minute
Dose adjustments
Discuss with pharmacy