Status Epilepticus - Management and Causes

Causes, Treatment, and Seriousness of Status Epilepticus

nerve cells in the brain
What is status epilepticus, why does it happen, and how is it treated?. Istockphoto.com/Stock Photo©Ralwel

Status epilepticus, or 'status' is a medical emergency that requires quick attention - in fact, quick medical care can save a life. 

Note: If you are concerned that someone has status epilepticus call 911. The new 2016 recommended emergency medication steps are noted below under emergency care.

A seizure is abnormal, disorganized electrical activity that occurs within the brain. If someone has recurrent seizures, a diagnosis of epilepsy is made based on blood studies, a comprehensive medical history, and other tests, such as an EEG, spinal tap, or imaging studies.

It is at this point that your healthcare provider will prescribe you the proper medications that will control your condition.

With epilepsy, you will find that most seizures may last up to a few minutes. In some rare instances, they may last longer and may, in fact, appear not to stop at all. This is referred to as status epilepticus. It is estimated that about 50,000 to 150,000 individuals in the United States are affected by status epilepticus every year.

What Is Status Epilepticus?

During status epilepticus, a person with epilepsy will have impaired consciousness and persistent or repetitive seizures. Normal seizures will last only a few minutes. However, when a seizure lasts 5 to 30 minutes without consciousness being regained, the individual will be diagnosed with status epilepticus.

Status epilepticus is a medical emergency that requires quick and careful medical treatment and could be deadly if not immediately addressed.

Complications that could arise from status epilepticus include dysfunction of the heart or lungs, metabolic changes, an increase in body temperature, and ultimately, irreversible brain injury.

Status epilepticus can be classified as convulsive or nonconvulsive. Convulsive means a person is having an obvious convulsive (shaking like) episode.

Nonconvulsive epilepticus refers to a state of confusion and impaired consciousness. Individuals in a nonconvulsive state will not appear to be having an obvious seizure, but they still have the electrical misfirings in the brain that are consistent with a seizure. After a convulsive seizure has stopped and the person has not regained consciousness after a period of time, a healthcare provider will consider performing an EEG to make sure the person is not in nonconvulsive status.

What Causes Status Epilepticus?

Status epilepticus is a critical and life-threatening condition that requires rapid and urgent medical treatment in order to prevent further complications and to preserve the brain function. Status epilepticus can affect any age group, although some factors are more likely to cause status in children and others more common in adults. These precipitating factors include:

  • Systemic infections (infections affecting large portions of the body)
  • Febrile (fever-related) disease
  • Head trauma
  • Stroke

Emergency Care of Status Epilepticus

The initial treatment begins with the ABC rules: Make sure the individual’s airway is clear, the individual is breathing and to restore the body fluid.

A medical assessment will also be performed to find out why the individual went into status epilepticus in the first place.

In order to control the seizures, certain medications will be used. New guidelines were put forth in 2016 by the American Epilepsy Society.

The first and preferred medications used are IV benzodiazepines, which include diazepam, lorazepam, and midazolam. Lorazepam is often used due to its fast action.  Roughly 55% of people will respond to this first approach.  If it is not working, one of these drugs may be repeated, but if it fails to work after the second dose, it is time to switch to different medications.

Options for second therapy step drugs include IV fosphenytoin, valproic acid, or levetiracetam.  If this does not work another one of these drugs can be used, or phenobarbital can be given.

If these second strategy phase drugs do not work, it is time to enter an aggressive phase with the use of continuous EEG monitoring.  The second therapy drugs may be repeated or the patient could be treated with anesthetic dose thiopental, medazolam, pentobarbital, or propofol.

Importance and Prognosis of Status Epilepticus

Status epilepticus can be deadly and should not be taken lightly. One study noted that the death rate for the population diagnosed with epilepsy was as high as 22%, with a mortality rate of 3% in children and 26% in adults. Therefore, quick action is very important.

Preventing Status Epilepticus

In order to prevent status epilepticus, individuals should be compliant with their antiepileptic medications. Additionally, regular visits to their healthcare provider should be made to ensure that the medication is working properly, no other medications have been added that could reduce the effectiveness of their antiepileptic medications, and to assess for any other conditions (such as alcoholism, uncontrolled diabetes, metabolic disturbances) that could interrupt seizure control.

Sources:

Betjemann, J., and D. Lowenstein. Status epilepticus. Lancet Neurology. 2015. 14(6):615-624.

Drislane, F. Convulsive status epilepticus in adults: Classification, clinical features, and diagnosis. UpToDate. Updated 11/20/15. http://www.uptodate.com/contents/convulsive-status-epilepticus-in-adults-classification-clinical-features-and-diagnosis

Glauser, T., Shinnar, S., Gloss, D. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Currents. 2016. 16(1):48-61.

Trinka, E., Cock, H., Hesdorffer. Et al. A definition and classification of status epilepticus--Report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia. 2015. 56(10):1515-23.

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