Treatment of Status Epilepticus

Treatment begins with standard emergency procedures such as maintaining an airway, starting an IV line for blood sampling and drug administration, and so on.28 The first drugs administered are usually benzodiazepines lorazepam (Ativan) or diazepam (Valium) 

Many people with seizure disorders will need to adhere to a regimen of antiseizure medications throughout 

Withdrawal of medications must, of course, be done under close medical supervision. Likewise, medications are usually tapered-off over an extended period of time (6 months) rather than being suddenly discontinued.7 Nonetheless, it appears that a large proportion of people with epilepsy may be able to maintain seizure-free status once their seizures are controlled by the appropriate medications. 

HPI BZ is a 24-year-old man s/p frontal craniotomy for resection of a meningioma. Prior to surgery, he was maintained on carbamazepine for his generalized seizures with good results. His carbamazepine level was 9 (jug/mL (normal 4-12 fjig/mL) prior to admission. Postoperatively, upon admission to the ICU, he had three generalized tonic-clonic seizures over 30 minutes. Though able to follow commands in the recovery room, he is new semiconscious. 

What are acute systemic concerns associated with status 

What objective data should be monitored during status 

Status epilepticus occurs in approximately 50,000 patients per year in the United States, and 10% to 35% have no prior history of seizures. Risk factors include acute cerebral insult and drug overdose or withdrawal. 

Status epilepticus is defined as more than 30 minutes of either continuous seizure activity or two or more sequential seizures without full recovery of consciousness between seizures. SE is a medical emergency because it can lead to permanent brain damage. Mortality is as high as 10% in children and 25% in adults. 

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Explain the urgency of diagnosis and treatment of status epilepticus. 

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. 

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

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. 

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,... 

It is used in prophylactic treatment of all varieties of partial epilepsy whether or not seizure becomes secondarily generalised. It is also used in prophylactic treatment of generalised convulsive seizures and treatment of status epilepticus prophylactic management of certain forms of supraventricular cardiac arrhythmia as it has an ability to selectively inhibit high frequency firing prophylactic management of certain... 

Treatment of status epilepticus—intravenous boluses or infusion. 

Two prominent aspects of benzodiazepines limit their usefulness. The first is their pronounced sedative effect, which is unfortunate both in the treatment of status epilepticus and in chronic therapy. Children may manifest a paradoxical hyperactivity, as with barbiturates. The second problem is tolerance, in which seizures may respond initially but recur within a few months. The remarkable antiseizure potency of these compounds often cannot be realized because of these limiting factors. 

Several members of the benzodiazepine group are effective in treating epilepsy, but most are limited because of problems with sedation and tolerance. Some agents such as diazepam (Valium) and lorazepam (Ativan) are used in the acute treatment of status epilepti-cus (see Treatment of Status Epilepticus ), but only a few are used in the long-term treatment of epilepsy. Clonazepam (Klonopin) is recommended in specific forms of absence seizures (e.g., the Lennox-Gastaut variant) and may also be useful in minor generalized seizures such as akinetic spells and myoclonic jerks. Clorazepate (Tranxene) is another benzodiazepine that is occasionally used as an adjunct in certain partial seizures. 

Therapeutic uses Phenytoin is highly effective for all partial seizures (simple and complex), for tonic-clonic seizures, and in the treatment of status epilepticus caused by recurrent tonic-clonic seizures (Figure 15.3). Phenytoin is not effective for absence seizures, which often may worsen if such a patient is treated with this drug. 

Drugs used in the treatment of status epilepticus Benzodiazepines, e.g., diazepam... 

De Negri M, Baglietto MG. Treatment of status epilepticus in children. Paediatr Drugs 2001 3 411-20. 

The use of diazepam in equine anesthesia is covered in Chapter 15. Although all of the benzodiazepines have some anticonvulsant activity, diazepam is the most popular for treatment of status epilepticus because it is distributed rapidly to the CNS after i.v. administration. The limbic, thalamic and hypothalamic areas of the CNS are depressed by diazepam, resulting in its anxiolytic, sedative, skeletal muscle relaxant and anticonvulsant effects. 

Galdames-Contreras, D., Carrasco-Poblete, E., Aguilera-Olivares, L., Fabres-Oyarzo, L. and Galdames-Poblete, D. 2006. Intramuscular midazolam in the initial treatment of status epilepticus. Rev. Neurol., 42 332-335. 

Koul RL, Aithala GR, Chacko A, et al. Continuous midazolam infusion as treatment of status epilepticus. Arch Dis Child 1997 76 445 48. 

Given the conditions and the requirements for the initial symptomatic treatment of mass casualties, the diazepam derivative avizafone in autoinjectors and/or midazolam for intramuscular injection should be sufficient. In view of lo-razepam s reported efficacy in treatment of status epilepticus, it is recommended that more experimental studies are performed on the efficacy of lorazepam, and also in controlling nerve-agent-induced seizures and convulsions. 

Local and spinal anesthetic also used for treatment of status epilepticus migraine and cluster headaches ventricular arrhythmias, ventricular fibrillation cardiac arrest neuropathic pain, postherpetic neuralgia... 

Although diazepam is an effective agent for treatment of status epilepticus, its short duration of action is a disadvantage, leading to the more frequent use of lorazepam. Although diazepam is not useful as an oral agent for the treatment of seizure disorders, clorazepate is effective in combination with certain other drugs in the treatment of partial seizures. The maximal initial dose of clorazepate is 22.6 mg per day in three portions for adults and 15 mg per day in two doses in children. Clorazepate is not recommended for children under the age of 9. 

Because it markedly lowers cerebral metabolism, thiopental has been used as a protectant against cerebral ischemia. At least one human study suggests that thiopental may be efficacious in ameliorating ischemic damage in the perioperative setting. Thiopental also reduces intraocular pressure. Perhaps due to their CNS depressant activity, barbiturates are effective anticonvulsants thiopental in particular is effective in the treatment of status epilepticus. 

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