Status Epilepticus
Saint Severin curing a woman of the "falling sickness demon"
Definition
- GTC duration > 5 min
Basics
- provoked or unprovoked
> provoked seizure; no need for ASM
- rhabdomyolysis
Medications
a) Benzodiazepine
Lorazepam 0.1 mg/Kg (max 4 mg/dose), may repeat 1x
- If no IV, midazolam 10 mg IM
b) ASM
- 1st levetiracetam
- 2nd VPA or PHT
- 3rd phenobarbital
Phenobarbital
20 mg/Kg
Fosphenytoin
20 mg/Kg
Max 1500 mg
VPA
40 mg/Kg
Max 2000
Levetiracetam
60 mg/Kg
Max 45000
c) Intubation
Propofol
Loading 1 mg/Kg
Infusion 20 mcg/Kg/min
Max 200 mcg/Kg/min
Ketamine
Loading 1.5 mg/Kg
Infusion 1.2 mg/Kg/h
Max 7.5 mg/Kg/h
Levels
- Loading level and through level
- VPA and phenytoin
Loading level: 1h after loading dose
Through level: 1h before 4th maintenance dose
(steady state is at 4th half-life)
EEG
- indicated, unless returned to baseline
- vEEG
> treat lateralized periodic discharges
Neuroimaging
- Diffusion changes without a vascular distribution support the diagnosis of status epilepticus, rather than an acute ischemic stroke
Adjunctive therapy
Lacosamide
- PR interval (< 200, no need if PPM)
- order level
- always load 200 mg, fu by 100 mg BID