Status epilepticus generalized convulsive

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 ... 

No. Antipyretics may make the child feel more comfortable, but there is no evidence that they reduce the incidence or severity of febrile convulsions. Anticonvulsants certainly have no role to play. If a febrile convulsion does happen they are generally tonic or tonic-clonic and last just a couple of minutes. If they were to continue for longer than 5 minutes then conventional treatment for status epilepticus should be used (rectal diazepam or buccal midazolam). 

The use of intravenous benzodiazepines administered by paramedics for the treatment of out-of-hospital status epilepticus has been evaluated in a double-blind, randomized trial in 205 adults (54). The patients presented either with seizures lasting 5 minutes or more or with repetitive generalized convulsive seizures, and were randomized to receive intravenous diazepam 5 mg, loraze-pam 2 mg, or placebo. Status epilepticus was controlled on arrival at the hospital in significantly more patients taking benzodiazepines than placebo (lorazepam 59%, diazepam 43%, placebo 21%). The rates of respiratory or circulatory complications related to drug treatment were 11% with lorazepam, 10% with diazepam, and 23% with placebo, but these differences were not significant. 

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. 

Generalized convulsive status epilepticus (GCSE) is defined as any recurrent or continuous seizure activity lasting longer than 30 minutes in which the patient does not regain baseline mental status. Any tonic-clonic seizure that does not stop automatically within 1 0 minutes should be treated. 

ALT, alanine aminotransferase AST, aspartate aminotransferase CBC, complete blood count CNS, central nervous system CT, computed tomography ECG, electrocardiogram EEG, electroencephalograph GCSE, generalized convulsive status epilepticus MRI, magnetic resonance imaging SE, status epilepticus... 

Treiman DM. Generalized convulsive status epilepticus in the adult. Epilepsia 1993 34(suppl 1) S2-11. 

TreimanDM, De Giorgio CM, Ben-Menachem E, etal. Lorazepam versus phenytoin in the treatment of generalized convulsive status epilepticus Report of an ongoing study. Neurology 1985 35 284. 

A 21-year-old man with idiopathic generalized epilepsy took about 8 g of topiramate in a suicide attempt and had non-convulsive status epilepticus, which was treated with intravenous lorazepam [30F ]. 

A 5-year-old boy with no history of convulsions had a generalized tonic-clonic seizure after taking oral theophylline for 2 days followed by non-convulsive status epilepticus [95 ]. The serum theophylline concentration was 19.7 mg/1. An intravenous bolus dose of midazolam 0.26 mg/kg largely restricted seizure activity to the right hemisphere and another 0.24 mg/kg followed by a continuous infusion of 0.20 mg/kg/hour completely abolished the electrical status. 

Skin A woman developed localized skin necrosis after intravenous administration of phenytoin for generalized convulsive status epilepticus. The authors consequently made some recommendations for the intravenous administration of phenytoin a dedicated intravenous caimula should be inserted in a large peripheral vein the rate of administration should not exceed 50 mg/minute the cannula should be periodically flushed with saline after each bolus continuous monitoring for signs of extravasation, hypotension, and bradycardia should be performed [253 ]. 

Observational studies A phase 111 study evaluated the safety and efficacy of levetiracetam in 217 children and adults with primary generalized seizures. The most common adverse effects reported by >10% participants were headache and nasopharyngitis. The most frequent treatment-associated adverse effects were headache (4.6%), dizziness and depression (both 4.1%). Serious adverse effects related to treatment with levetiracetam 4.6% of patients experienced convulsion, atrial fibrillation, epilepsy, depression, psychosis, schizophrenia, suicidal ideation, erythematous rash, and status epilepticus. One patient each discontinued due to the following adverse effects arrhythmia, convulsions, tremor, aggression, depression, psychosis, and exanthem. One patient with worsening of comorbid schizophrenia committed suicide it had been 43 days since he had last taken levetiracetam at the time [87 -]. 

Brigo F, Storti M, Del Felice A, Fiaschi A, Bongiovanni LG. IV Valproate in generalized convulsive status epilepticus a systematic review. Eur J Neurol September 2012 19(9) 1180-91. 

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