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Home | Articles | Neurology | Status Epilepsy in Adults

Status Epilepsy in Adults

Last updated 3rd December 2020
Content by Dr Ondrej Dolezal

Introduction

  1. Generalised, convulsive status epilepticus refers to >5 min of continuous seizures or two or more discrete seizures between which there is incomplete recovery of consciousness.
  2. The priority in management is to achieve rapid termination of the seizures, regardless of the agent used. Treatment should not be delayed due to uncertainty surrounding appropriate drug choice.
  3. If uncertain, contact on call Medical Consultant for advice

Immediate Measures

  1. Adopt ABCDE approach
  2. Secure airway and give oxygen, monitoring SpO2
  3. Establish IV access with large forearm cannula
  4. Take blood for bedside BG and for FBC, U&E, LFTs, Calcium, Glucose, Clotting, AED levels
  5. Measure blood gases to assess extent of acidosis

Consider Reversible Factors

  1. If suggestion of hypoglycaemia, give 125ml Glucose 20% IV
  2. If  suggestion of alcohol abuse, give three pairs Pabrinex (ampoules 1 and 2) IV infusion over 20 min in 100ml sodium chloride 0.9% or 5% glucose

Antiepileptic Drug (AED) Treatment

  1. The results of a recently published Established Status Epilepticus Treatment Trial (ESETT) have demonstrated no significance in efficacy or adverse effects between fosphenytoin, levetiracetam or valproic acid.
  2. Levetiracitam is first line choice. NOTE: the dosage for levetiracitam and sodium valproate is outwith the manufacturer’s licence.

Administration of Drugs

  1. All should be flushed with 0.9% sodium chloride.
  2. Levetiracetam: administer in 100ml of 0.9% sodium chloride or 5% dextrose over 10 minutes.
  3. Phenytoin: administer in 50-100ml 0.9% sodium chloride (concentration not to exceed 10mg/ml) at rate not exceeding 50mg/minute.  Ensure working cannula in large vein prior to infusion due to risks associated with extravasation.
  4. Sodium valproate: administer in 50ml of 0.9% sodium chloride or 5% glucose over 10 minutes.

Special Circumstances

  1. Patient already prescribed Levetiracetam – Levetiracetam can be used as the first-choice anticonvulsant drug during Stage 2 at full dose, even if the patient is already prescribed levetiracetam in the community.  Levetiracetam levels are not available acutely, and it is likely that compliance is poor if the patient presents with status epilepticus.  If there is concern about administering levetiracetam in this context, valproate or phenytoin can be given instead.
  2. Pregnancy – Levetiracetam is the preferred Stage 2 drug in pregnancy.  Avoid sodium valproate where possible (risk of teratogenicity).
  3. Known renal failure – Levetiracetam remains first choice, but maintenance dose may need to be reduced (see dosing table below).

Maintenance Doses of Anticonvulsant Drugs

  1. Levetiracetam: start 1000-1500mg IV/oral/NG BD 10-12 hours after loading dose. Aim for reasonable dosing times 12 hours apart.
  2. Maintenance doses of Levetiracetam in renal impairment: (More information available from Renal Drug Database)
    Creatinine ClearanceDose
    50-79ml/min1000mg BD
    30-49ml/min750mg BD
    <30ml/min500mg BD
    In CVVHD dialysis give 750mg once daily. For other forms of dialysis consult renal physician.
  3. Phenytoin: start 300mg daily (300mg IV OD, 300mg oral capsules OD, or 100mg IV TDS).  Prescribe 270mg OD if using oral liquid. Start 6-8 hours after loading dose. Check phenytoin trough level 24-48 hours after starting maintenance dose.  If phenytoin is to be administered down a feeding tube contact pharmacy for advice.
  4. Sodium valproate: start 1000-1200mg IV or oral BD at least 6 hours after loading dose.

Links

  1. Kapur J, Elm J, Chamberlain JM, Barsan W, Cloyd J, Lowenstein D, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019 28;381(22):2103–13
  2. Status Epilepticus Clinical Guideline (Version1.0) – The Walton Centre NHS Foundation Trust, May 2020 [pdf]