Status epilepticus treatment

Working Group on Status Epilepticus. Treatment of convulsive stams epilepticus Recommendations of the Epilepsy Foundation of America s Working Group on Status Epilepticus. JAMA 1993 270 854—859. 

Explain the urgency of diagnosis and treatment of status epilepticus. 

Identify the treatment options available for termination of status epilepticus. 

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

The first-line treatment for status epilepticus is intravenous benzodiazepines. Diazepam, lorazepam, or midazolam may be used to rapidly control clinical signs of seizures. Lorazepam is currently considered the first-line agent by most clinicians. 

The goals of treatment of status epilepticus include the cessation of any seizure activity, both clinical and subclinical, and the prevention of further seizures. Ideally, this is accomplished through directed pharmacotherapy with minimization of any side effects or adverse reactions. Complications ofSE should also be treated. 

TABLE 28-3. Randomized, Prospective Trials Comparing Treatments for Status Epilepticus in Adults... 

Alldredge BK, Gelb AM, Isaacs SM, et al. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N Engl J Med 2001 345 631-637. 

Claassen J, Hirsch LJ, Emerson RG, et al. Treatment of refractory status epilepticus with pentobarbital, propofol, or midazolam a systemic review. Epilepsia 2002 43 146-153. 

The preferred treatment of status epilepticus is intravenous administration of... 

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

Alcohol withdrawal seizures do not require anticonvulsant drug treatment unless they progress to status epilepticus. Patients with seizures should be treated supportively. An increase in the dosage and slowing of the tapering schedule of the BZ used for detoxification or a single injection of a BZ may be necessary to prevent further seizure activity. 

Coleman BR, Ratcliffe R, Oguntayo S, Shi X, Doctor B, Gordon R, Nambiar M. (2008) [-i-]-Huperzine A treatment protects against A-methyl-d-aspartate-induced seizure/status epilepticus in rats. Chembiol Interact 175 387-395. 

The brief duration of a single epileptic fit makes acute drug treatment unfeasible. Instead, antiepileptics are used to prevent seizures and therefore need to be given chronically. Only in the case of status epilepticus (a succession of several tonic-clonic seizures) is acute anticonvulsant therapy indicated — usually with benzodiazepines given i.v. or, if needed, rectally. 

Status epilepticus Valid estimates of the incidence of treatment-emergent status epilepticus among lamotrigine-treated patients are difficult to obtain. At a minimum,... 

Status epilepticus Among the patients treated with tiagabine across all epilepsy studies (controlled and uncontrolled), 5% had some form of status epilepticus. Of the 5%, 57% of patients experienced complex partial status epilepticus. A critical risk factor for status epilepticus was the presence of the condition history 33% of patients with a history of status epilepticus had recurrence during tiagabine treatment. 

Paraldehyde, although not a drug of first choice, can be used for sleep induction. It is also still considered to be of some value in the treatment of status epilepticus. 

Refractory status epilepticus that has failed to respond to one of these treatments, and has continued for more than 20-30 min, requires urgent action. The accepted strategy is to paralyze and ventilate the patient and administer an antiepileptic drug in sufficient dosage to suppress EEG evidence of seizure activity. The barbiturate anaesthetic thiopental (thiopentone), the benzodiazepine midazolam, and the anaesthetic propofol have all been used. What little comparative evidence there is remains inconclusive. Such treatment can only be carried out with facilities for artificial ventilation and intensive care, and effects can only be monitored by EEG recording. 

Treiman DM, Meyers PD, Walton NY, Collins IF, Colling C, Rowan AJ et al. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group. N Engl J Med 1998 339(12) 792-8. 

The primary action of the benzodiazepines as anticonvulsants is to enhance inhibition through their interaction with the GABAa receptor at the benzodiazepine binding site. However, there appears to be an additional action of benzodiazepines blocking voltage-dependent sodium channels. This effect is not seen at usual doses but is likely a factor in their use in the treatment of status epilepticus (discussed later). 

Benzodiazepines are well absorbed, and the oral route is preferred in most situations. In the treatment of status epilepticus, the preferred route is usually intravenous. Benzodiazepines are extensively metabolized by the microsomal drug-metabohzing system frequently an active compound is broken down to another agent that is also active pharmacologically. This is the reason for the long duration of action of several benzodiazepines. 

The benzodiazepines have many clinical indications and are discussed in Chapters 25, 30, 35, and 40. As AEDs, they have their major usefulness in the treatment of absence, myoclonic, and atonic seizures and in the emergency treatment of status epilepticus. 

Lorazepam is the benzodiazepine of choice for emergency treatment of status epilepticus, serial seizures,... 

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