Convulsive status epilepticus

Formulate an initial treatment strategy for a patient in generalized convulsive status epilepticus. 

ED, emergency department GCSE, generalized convulsive status epilepticus SE, status epilepticus. 

Treiman DM, Meyers PD, Walton NY, et al. A comparison of four treatments for generalized convulsive status epilepticus. N Engl J Med 1998 339 792-798. 

FIGURE 56-1. Algorithm for the management of generalized convulsive status epilepticus. (CBC, complete blood cell count EEG, electroencephalogram HR, heart rate PE, phenytoin sodium equivalents PR, per rectum RR, respiratory rate.)... 

TABLE 56-2 Medications Used in the Initial Treatment of Generalized Convulsive Status Epilepticus l... 

TABLE 56-3 1 Medications Used to Treat Refractory Generalized Convulsive Status Epilepticus ... 

Cock HR, Schapira AH. A comparison of lorazepam and diazepam as initial therapy in convulsive status epilepticus. QJM 2002 95(4) 225-31. 

One recent report also detailed three cases of convulsive status epilepticus after abrupt discontinuation of long-term use of 25 mg lorazepam in one patient and more than 20 mg flunitrazeparr, in two patients. These patients were nonepileptics and free of other high-risk factors for seizure ( 271). 

Gatzonis SD, Angelopoulos EK, Daskalopoulou EG, et al. Convulsive status epilepticus following abrupt high-dose benzodiazepine discontinuation. Drug Alcohol Depenc 2000 59 95-97. 

The therapeutic plasma level of phenytoin for most patients is between 10 and 20 g/mL. A loading dose can be given either orally or intravenously the latter, using fosphenytoin, is the method of choice for convulsive status epilepticus (discussed later). When oral therapy is started, it is common... 

Non-convulsive status epilepticus occurred in a 27-year-old woman shortly after starting treatment with clomipramine and maprotiline (15). On withdrawal of medication she gradually improved. 

Miyata H, Kubota F, Shibata N, Kifune A. Non-convulsive status epilepticus induced by antidepressants. Seizure 1997 6(5) 405-7. 

Kuruvilla PK, Alexander J. Lithium toxicity presenting as non-convulsive status epilepticus (NCSE). Aust NZ J Psychiatry 2001 35(6) 852. 

Two patients developed non-convulsive status epilepticus and neuroleptic malignant syndrome (356). Whether this constitutes one syndrome or merely the co-existence of the two is academic, because it makes no difference to therapy. 

In a fatal case of olanzapine overdose a cardiac dysrhythmia, non-convulsive status epilepticus, and persistent choreoathetosis occurred consecutively (253). 

In a multicenter, randomized, double-blind comparison of diazepam (0.15 mg/kg followed by phenytoin 18 mg/kg), lorazepam (0.1 mg/kg), phenobarbital (15 mg/kg), and phenytoin (18 mg/kg) in 518 patients with generalized convulsive status epilepticus, lorazepam was more effective than phenytoin and at least as effective as phenobarbital or diazepam plus phenytoin (1). Drug-related adverse effects did not differ significantly among the treatments and included hypoventilation (up to 17%), hypotension (up to 59%), and cardiac rhythm disturbances (up to 9%). 

Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, Handforth A, Faught E, Calabrese VP, Uthman BM, Ramsay RE, Mamdani MBVeterans Affairs Status Epilepticus Cooperative Study Group. A comparison of four treatments for generalized convulsive status epilepticus. N Engl J Med 1998 339(12) 792-8. 

In 27 children with refractory generalized convulsive status epilepticus, midazolam 0.2 mg/kg as a bolus followed by 1-5 (mean 3.1) micrograms/kg/minute as a continuous infusion achieved complete control of seizures in 26 children within 65 minutes (14). There were no adverse effects, such as hypotension, bradycardia, or respiratory depression. In one patient with acute meningoencephalitis, status epilepticus could not be controlled. Five patients died of the primary disorders, one with progressive encephalopathy. 

In contrast, occasional reports that allopurinol may have an anticonvulsive effect prompted its use in therapy-resistant epileptic patients. Withdrawal in one of these patients precipitated a convulsive status epilepticus (SEDA-16,114). 

Five patients developed severe symptoms after receiving cefepime (31). The patients, three men and two women, aged 16-75 years, received 2 g/day (n — 3) A g/day n = 1) or 9 g/day n — 1). The symptoms started 12-16 days after the start of therapy. In all cases, the initial neurological symptoms (disorientation, confusion, and reduced consciousness) were progressive and were attributed to the infection. Facial or multifocal myoclonic movements occurred subsequently and were rapidly followed by convulsive or non-convulsive status epilepticus. The dose of cefipime had not been adjusted for renal function in any of the patients. Cefepime serum concentrations were measured in three cases, and were 72, 73, and 134 gg/ml. All the patients underwent hemodialysis, and the serum concentrations of cefepime fell to 4.3, 21, and 25 gg/ml respectively. In the other two patients, the serum concentrations after dialysis were 14 and 54 gg/ml, suggesting high concentrations before dialysis. There was complete recovery in four of the patients. One, a 73-year-old woman, died of multiorgan failure with refractory status epilepticus and coma. The authors referred to four... 

Non-convulsive status epilepticus has been attributed to fluorescein. 

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