Estado de mal convulsivo. Protocolo terapêutico.

Abstract

Convulsive status epilepticus (CSE) in a medical emergency with a prognosis associated to its duration, claiming an early and effective treatment. The authors present the treatment protocol proposed at the Hospital de Santa Maria. The chosen definition of CSE allows its rapid treatment, and the electroencephalographic record the monitoring of its real efficacy. The treatment protocol is initiated whenever there are: continuous seizures persisting for more than 5 min, or two or more seizures surveying without regain of consciousness between them. The goal is stopping convulsive activity in less than 30 min and interrupting any epileptiform electroencephalographic activity. The initial pharmacological treatment of CSE includes lorazepam and fosphenitoin, a phenitoin prodrug. The first is chosen by the longer duration of its antiseizure effect as compared with diazepam; the second allows the administration of an identical dose but in a shorter period of time as compared to the mother drug; besides, it has few local and systemic effects and can be given intramuscularly after stopping the CSE. Drugs with a rapid clinical effect and rapid clearance, as midazolam and propofol should be used for treating refractory SE. Pentobarbital is the last anesthetic drug to be used because of its adverse cardiovascular effects and long-lasting action which can delay weaning from ventilatory support.