Management Of Status Epilepticus Research Articles

Analysis of the Delay Components in the Treatment of Status Epilepticus

The factors comprising the delays in management of status epilepticus (SE) have not been systematically studied. We studied retrospectively all adult patients (N = 82) diagnosed with SE in Helsinki University Central Hospital emergency room over a 2-year period. We analyzed prehospital, diagnostic, treatment, and treatment response delays based on medical records and quantitatively evaluated data availability and accuracy. SE manifested mostly without any warning symptoms, but every fifth case presented a pre-status period. Median prehospital delay was 2 h 4 min, including delays in emergency call, ambulance arrival, and patient transportation. Median delay of diagnosing SE was 2 h 10 min. EEG-based diagnosis was significantly delayed compared to clinical diagnosis. Median delay in recording EEG was 22 h 2 min. Median delay of the first medication was 35 min, and those of second- and third-stage medications were 3 h and 2 h 55 min, respectively. We applied stepwise definition for treatment response and counted delays accordingly: total convulsion period 5 h 52 min, Burst-suppression (BS) 17 h 30 min and return of consciousness 47 h 40 min. Median treatment period in intensive care unit was 2.7 days. Mortality over treatment period (median 7.7 days) was 8.5 %. No post-discharge follow-up was performed. Our study reveals unexpectedly and unacceptably long delays in SE management, stressing the importance of commitment to acknowledged management protocol. Delays in the treatment can and need to be shortened markedly by several strategies discussed in this article.

Management of Status Epilepticus in Neurological Versus Medical Intensive Care Unit: Does it Matter?

Admission of patients with status epilepticus (SE) to the neurosciences intensive care unit (NICU) may improve management and outcomes compared to general ICUs. We reviewed all patients with SE admitted to the NICU versus the Medical ICU in our institution between 2005 and 2008. We included only patients with definite or probable SE based on pre-defined criteria. We collected demographic and clinical data, including severity of admission scores and adjusted short-term outcomes for admission and management in the two ICUs. There were 168 visits in 151 patients for definite or probable SE, 46 (27 %) of which were in the NICU and 122 (73 %) in the MICU. APACHE II scores were significant higher in the MICU group (17.5 vs 13.4, p = 0.003) and age in the NICU (58.3 vs 51.5 years, p = 0.041). More continuous EEGs were ordered in the NICU (85 vs 30 %, p < 0.001), where fewer patients were intubated, but more eventually tracheostomized. The NICU had a higher rate of complex partial SE and more alert or somnolent patients, whereas the MICU had a higher rate of generalized SE and more stuporous or comatose patients. Admission diagnoses also differed, with the NICU having higher rate of strokes and the MICU higher rate of toxometabolic etiologies (39 vs 12 % and 11 vs 21 %, p = 0.002). After adjustment, no difference was found in mortality, the ICU or hospital length of stay and modified Rankin score at discharge. SE treatment revealed increased use of continuous EEG in NICU-admitted patients, but without concomitant reduction in LOS or discharge outcomes compared to the MICU.

Critical appraisal of “Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W, NETT Investigators. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med. 2012 Feb 16;366(7):591–600”

<h2>Abstract</h2><h3>Background</h3> Intravenous benzodiazepines have been shown to be effective in management of status epilepticus, but due to ease of administration intramuscular route is being frequently used in prehospital care without documented evidence. <h3>Methods</h3> A double-blinded randomised clinical trial aiming to demonstrate that intramuscular midazolam is at least as effective as intravenous lorazepam (non-inferiority design). The non-inferiority margin was set at 10 percentage points below that of intravenous lorazepam's effect. Children and adults found in status epilepticus were included in the study and the interventions given serially by an intramuscular autoinjector followed by intravenous infusion. Double dummy strategy was followed so that each subject received either intramuscular midazolam or intravenous lorazepam along with a placebo. These subjects were followed thereafter for cessation of seizures on arrival to hospital (primary outcome) without the need for rescue therapy. Secondary outcomes included requirement of endotracheal intubation, recurrence of seizures, and timing of treatment relative to the cessation of convulsions. <h3>Results</h3> After screening and exclusion 893 subjects were assigned to interventions, 448 in the intramuscular midazolam group and 445 in the intravenous lorazepam group. Of the 448 of the former group 443 actually received the intervention while the intervention could be given in only 297 in the later group, 329 of 448 subjects (73.4%) in the intramuscular midazolam group and 282 of 445 (63.4%) in the intravenous lorazepam group (absolute difference, 10 percentage points; 95% confidence interval, 4.0–16.1; <i>P</i> < 0.001 for both non-inferiority and superiority) had no seizures on arrival to the emergency without the need for rescue therapy. There was no difference between the two intervention groups with regards to the need of endotracheal intubation or recurrence of seizures. the median times to administration of active treatment in the intramuscular midazolam group were 1.2 and 4.8 min in the intravenous lorazepam group, with median times from active treatment to cessation of convulsions of 3.3 min and 1.6 min in the two groups respectively. <h3>Conclusions</h3> In the management of status epilepticus, intramuscular midazolam was at least as safe and effective as intravenous lorazepam for prehospital control of seizure with lesser time required for its administration.

German-wide survey on the management of status epilepticus in children

German-wide survey on the management of status epilepticus in children

Epilepsy and nonepilepsy surgery: Recent advancements in anesthesia management.

Epilepsy is one of the most common encountered neurological disorders. Surgical procedures in epileptic patient throw numerous challenges to the attending anesthesiologist during the perioperative period. Various anesthetic drug interactions with antiepileptics, intraoperative and postoperative seizures management and management of status epilepticus are few considerations which an anesthesiologist can confront both during emergency or elective surgery. The role of anesthesiologist acquires significant dimensions in management of epilepsy ranging from operative procedure, status epilepticus to the intensive care management of such patients. It requires a skilful and clinically precise handling of such patients during pre-op, peri-op and post-op period. Majority of times these patients present with co-morbidities which makes the prophylactic management of epilepsy extremely difficult during surgical procedures. The responsibilities of anesthesiologist involve management of epileptic patients not only during epilepsy and nonepilepsy surgery but for other diagnostic and therapeutic procedures as well where sedation or anesthesia services are required. Postoperative management of such patients include careful observation for any seizures and/or pseudo-seizures so as to manage appropriately. The knowledge regarding various antiepileptic agents and their potential side effects and interactions with anesthetic agents are of prime concern during surgical procedures for epilepsy and nonepileptic surgeries. The present article discusses the various anesthetic implications and considerations during management of such patients for epilepsy and nonepilepsy surgery.

Review of Levetiracetam as a First Line Treatment in Status Epilepticus in the Adult Patients – What Do We Know so Far?

With the advent of new antiepileptic drugs comes the potential for significant advances in the emergent management of status epilepticus. Traditional antiepileptic drugs possess side effect profiles that may limit their clinical utility or lead to increased patient morbidity or mortality. The relatively recent development of levetiracetam shows promise for effective control of acute status epilepticus in adults, but current objective data of its use as a first-line agent for control of status is quite limited. This paper serves to examine existing literature while considering levetiracetam as a first-line therapy in status in the adult patient population. Although existing studies are narrow in their scope, the present data lay a substantial foundation for further investigation of levetiracetam as a primary therapy in acute status epilepticus.

974 PICU Outreach Education Improves Local Management of Status Epilepticus (Se)

Background and AimsIn september 2011 results of an audit on the acute management of SE in referring hospitals highlighting safety and feasibility of extubation in some children avoiding transfer to...

Seizure management at Auckland City Hospital Emergency Department between July and December 2009: time for a change?

To assess the management of epileptic seizures and status epilepticus in adult patients at Auckland City Hospital emergency department. This information will form the basis of future seizure management protocols and further research on the management of status epilepticus. The prehospital and acute hospital management of all adult seizure patients seen between 1 July 2009 and 31 December 2009 was reviewed with respect to seizure type, presence of first seizure, pre-existing epilepsy diagnosis and disposition from the emergency department. Two hundred and fifty-five seizure events were identified in 227 patients. Nineteen patients presented twice during the study period and three patients presented three or more times. Generalised seizures were much more common than focal seizures. There were 75 presentations with first seizure (29.4%). Thirty-seven patients (49.3%) with a first seizure received treatment with an anti-epileptic drug. Status epilepticus occurred on 12 occasions (4.7%) with only three patients receiving lorazepam as treatment. The majority of seizure patients were managed by emergency department staff (58.4%) while general medicine (17.6%) and neurology (11.8%) teams managed fewer patients. Phenytoin was used in 56 patients (22%) with the majority (n= 43) receiving intravenous phenytoin. Many of the patients who received intravenous phenytoin were not subsequently discharged on that medication (46%). More patients than would be expected received treatment after their first seizure. Phenytoin was a widely used anti-epileptic drug. There was a wide variability in the management of status epilepticus, and intravenous lorazepam was underutilised.

Guidelines for Status Epilepticus: Are We There Yet?

Guidelines are a curate’s egg. They are to be welcomed for the obvious reason that clinicians need advice, and especially so in emergency settings, and the simple fact that in status epilepticus, for instance, the adoption of a protocol improves outcome. Also, it is important to take a scientific approach to the evaluation of evidence, and guidelines offer this potential. Herein, however, lie their drawbacks. Hard evidence is scarce on the ground in many clinical situations and where strictly evidence-based recommendations only are made in a guideline, the guidelines tend to be bland and self-evident. Conversely, where the guideline strays from the evidence-based path, there is an inevitable adoption of subjective and selective opinion. The therapy of status epilepticus presents a classic example of this problem. In this issue, ‘Guidelines for the evaluation and management of status epilepticus’ are published [1]. The authors, who were appointed by the Neurocritical Care Society, recognised the lack of controlled data and have opted for a less stringent approach than is often taken— categorising their recommendations according to the GRADE system [2], rather than the more testing schema usually chosen. This is a good decision allowing the recommendations to be wider than would otherwise be the case. However, there is much that is opinion and whether this article would best be considered a ‘consensus statement’ is a moot point. All other guidelines in the field of status epilepticus, of which there are a large number, have similar limitations. A definition of status epilepticus as a seizure prolonged beyond 5 min is a formulation increasingly adopted, in place of the traditional definition requiring 30 min. Whatever the definition, all are agreed that the therapy of status should be ‘staged’ and this is confirmed in these guidelines. These guidelines rather unnecessarily change the commonly used terminology used in staging, referring to firststage therapy as ‘emergent’ (quite what is meant by this term is not clear; if it means urgent—then surely this applies to therapy at all stages) and the second stage as ‘Urgent Control Therapy’ (therapy at all stages aims at urgent control). The stage of initial therapy has been the subject of the most definitive investigation. On the basis of a number of major studies almost all authorities agree that parenteral benzodiazepines are the preferred choice. However, which drug should be used, in what dose and by what route of administration are all less certain. Much depends on whether the patient is in hospital or outside and this distinction is not given emphasis in these guidelines. Where out-ofhospital therapy is given (i.e where facilities for resuscitation are not present), non-IV benzodiazepine is recommended. The recent publication of the RAMPART study, a landmark in the field shows how effective IM midazolam is as out-of-hospital therapy can be. There is also no mention of intranasal or buccal use of midazolam which is certainly the treatment of first choice in out-ofhospital settings in Europe, and indeed is supported by large-scale controlled studies. It seems likely that all IV benzodiazepines are equally effective, any differences in the studies due to differences in doses—but the therapeutic effects of lorazepam are longer-lasting and lorazepam has kinetic advantages which give it the edge as in-hospital IV therapy. Another point which certainly would not be agreed by all is the recommendation that after control with benzodiazepines, IV antiepileptics should always be given. There surely are many seizures, lasting 5 min or more and S. Shorvon (&) UCL Institute of Neurology, London, United Kingdom e-mail: s.shorvon@ucl.ac.uk

Guidelines for the Evaluation and Management of Status Epilepticus

Status epilepticus (SE) treatment strategies vary substantially from one institution to another due to the lack of data to support one treatment over another. To provide guidance for the acute treatment of SE in critically ill patients, the Neurocritical Care Society organized a writing committee to evaluate the literature and develop an evidence-based and expert consensus practice guideline. Literature searches were conducted using PubMed and studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using standardized assessment methods from the American Heart Association and Grading of Recommendations Assessment, Development, and Evaluation systems, as well as expert opinion when sufficient data were lacking.

Status Epilepticus: A Review, With Emphasis on Refractory Cases

Status epilepticus is among the most dramatic of clinical presentations encountered by emergency room physicians, neurologists, neurosurgeons and intensivists. While progress in its management has been aided significantly with an increasing number of effective treatment options, improved diagnostic methods and more effective monitoring, poor outcomes and diagnostic failures are still frequently encountered. Refractory cases still carry significant morbidity and mortality rates, including poor cognitive outcomes. This review discusses basic pathophysiology and management of status epilepticus, neuroimaging findings, the role of continuous electroencephalogram monitoring and nonconvulsive status epilepticusas well as recent developments in treatment options for refractory cases.

Modern electroencephalography

Electroencephalography (EEG) has been in continuous development over at least 70 years and is firmly established as a tool in the management of epilepsy. For a while, the technique fell into disregard because of difficulties with interpretation, specificity and sensitivity. Whilst clinicians have to be aware of these problems, they have been largely addressed by recent computer digitization of signals, which permits longer standard recordings and monitoring linked to a simultaneous video. These techniques are not only an essential component of a specialist epilepsy service, where inpatient video-EEG telemetry is vital both for diagnosis and assessment before neurosurgical treatment, but also in general and acute medical settings, particularly for the management of status epilepticus. Further developments in computing will extend the use of EEG in all of these roles and long-term monitoring for diagnosis and management of coma will become more widely available.

Complications of the management of status epilepticus in the intensive care unit

Barbiturates and propofol are widely used to control status epilepticus. This review aims to discuss all possible adverse effects incurred by the administration of GABA-mediated anesthetic agents. Further on unconventional therapies such as ketamine, lidocaine, or anesthetic agents are discussed both with respect to efficacy and complications. The aim of this review is to raise awareness of complications incurred by therapeutic approaches to patients with status epilepticus in the intensive care unit.

Levetiracetam versus lorazepam in status epilepticus: a randomized, open labeled pilot study

For the management of status epilepticus (SE), lorazepam (LOR) is recommended as the first and phenytoin or fosphenytoin as the second choice. Both these drugs have significant toxicity. Intravenous levetiracetam (LEV) has become available, but its efficacy and safety has not been reported in comparison to LOR. We report a randomized, open labeled pilot study comparing the efficacy and safety of LEV and LOR in SE. Consecutive patients with convulsive or subtle convulsive SE were randomized to LEV 20mg/kg IV over 15min or LOR 0.1mg/kg over 2-4min. Failure to control SE within 10min of administration of one study drug was treated by the other study drug. The primary endpoint was clinical seizure cessation and secondary endpoints were 24h freedom from seizure, hospital mortality, and adverse events. Our results are based on 79 patients. Both LEV and LOR were equally effective. In the first instance, the SE was controlled by LEV in 76.3% (29/38) and by LOR in 75.6% (31/41) of patients. In those resistant to the above regimen, LEV controlled SE in 70.0% (7/10) and LOR in 88.9% (8/9) patients. The 24-h freedom from seizure was also comparable: by LEV in 79.3% (23/29) and LOR in 67.7% (21/31). LOR was associated with significantly higher need of artificial ventilation and insignificantly higher frequency of hypotension. For the treatment of SE, LEV is an alternative to LOR and may be preferred in patients with respiratory compromise and hypotension.

Valproate versus diazepam for generalized convulsive status epilepticus: a pilot study

Evidence-based data to guide the management of status epilepticus (SE) after failure of primary treatment are still scarce and the alternate needs to be found when phenytoin (PHT) is not available or contraindicated. Comparison of intravenous (IV) valproate (VPA) and diazepam (DZP) infusion has not been conducted in adults with SE. This prospective randomized controlled trial is thus designed to evaluate the relative efficacy and safety of IV VPA and continuous DZP infusion as second-line anticonvulsants. After failure of first-line anticonvulsants treatment, patients with generalized convulsive status epilepticus (GCSE) were randomized to receive either IV VPA or continuous DZP infusion. Primary outcome was the proportion of patients with effective control. Side effects were also evaluated. There were 66 cases enrolled, with the mean age of 41 ± 21 years. Seizure was controlled in 56% (20/36) of the DZP group and 50% (15/30) of the VPA group (P = 0.652). No patient in the VPA group developed respiratory depression, hypotension, or hepatic dysfunction, whereas in the DZP group, 5.5% required ventilation and 5.5% developed hypotension. Time (hour) for regaining consciousness after control was near-significantly longer in the DZP group [13(3.15-21.5)] than in the VPA group [3(0.75-11)] (P = 0.057). Virus encephalitis and long duration of GCSE were independent risk factors of drug resistance. Both IV VPA and continuous DZP infusion are effective second-line anticonvulsants for GCSE. IV VPA was well tolerated and free of respiratory depression and hypotension, which may develop in the DZP group. Outcome parameters were not significantly different between groups.

The acute and chronic effects of the novel anticonvulsant lacosamide in an experimental model of status epilepticus

The effective management of status epilepticus (SE) continues to be a therapeutic challenge. The aim of this study was to investigate the efficacy of lacosamide treatment in an experimental model of self-sustaining SE. Rats were treated with lacosamide (3, 10, 30 or 50mg/kg) either 10 min (early treatment) or 40 min (late treatment) after the initiation of perforant path stimulation. Early lacosamide treatment significantly and dose-dependently reduced acute SE seizure activity; late treatment showed only a non-significant trend toward reduced seizure activity. Early lacosamide treatment also dose-dependently reduced the number of spontaneous recurrent seizures following a 6-week waiting period, with 70% reduction at the highest dose tested (50mg/kg); there was also a significant reduction in the number of spikes and the cumulative time spent in seizures. Late treatment with high-dose lacosamide (30-50mg/kg) reduced the number of animals that developed spontaneous recurrent seizures (33% vs 100% in controls, P<.05), but did not significantly reduce seizure severity or frequency in rats that developed spontaneous recurrent seizures. The results presented here suggest that lacosamide deserves investigation for the clinical treatment of SE. Potential for disease modification in this rat model of self-sustaining SE will require further studies.

Status epilepticus in the elderly: differential diagnosis and treatment

Seizures are not an uncommon occurrence in older adults, and the incidence of status epilepticus is much greater in the elderly than in younger populations. Status epilepticus is a neurologic emergency and requires prompt intervention to minimize morbidity and mortality. Treatment involves both supportive care as well as initiation of medications to stop all clinical and electrographic seizure activity. Benzodiazepines are used as first-line agents, followed by antiepileptic drugs when seizures persist. In refractory status epilepticus, urgent neurologic consultation is indicated for the titration of anesthetic agents to a level of appropriate background suppression on EEG. In light of our aging population, physician awareness and competence in the management of status epilepticus is imperative and should be recognized as a growing public health concern.

Generalized convulsive status epilepticus management in adults: A cohort study with evaluation of professional practice

Generalized convulsive status epilepticus (GCSE) needs immediate management. Despite guidelines, adherence to management protocols is often poor, this contributing to poor outcome. We aimed to evaluate the usefulness of a management protocol in GCSE. This is a prospective population-based study of consecutive adults with GCSE in Haute-Garonne district, France. Demographics and treatment procedures were documented. Factors associated with seizure termination and refractoriness were analyzed using logistic regression. One hundred eighteen episodes in 111 adults (mean age 55 years) between October 2006 and February 2008 were included. SE was convulsive in 101 episodes. Incidence was 6.6 per 100,000 and case fatality was 9%. Adequate initial treatment according to protocol was observed in 38%; 64% were treated out-of-hospital, and SE was refractory in 27% [no response after two antiepileptic drugs (AED)]. Patients who received adequate first-line treatment were 6.8 times [95% confidence interval (CI) 2.8-16.9] more likely to have seizure termination, with 74% versus 29% efficacy rate (p < 0.0001). Inadequate initial management was 4.7 times (1.9-11.1) more likely to need several benzodiazepine doses (p = 0.0004) and 9.1 times (3.7-20) more likely to require a long-acting AED as next treatment (p < 0.0001). Seizure termination after initial treatment was associated with decreased intensive care unit stay [1 (1-2) versus 2 (1-5.5) days, p < 0.0001] and hospital stay [3 (2-11) versus 7 (3-18) days, p = 0.009]. GCSE termination and outcome seem clearly associated with adherence to treatment protocol. Results add to the debate on appropriate allocation of resources for out-of-hospital treatment, licensed drugs, and achievement of guideline implementation to improve SE outcome.

Case Series: Continuous electroencephalographic monitoring of status epilepticus in dogs and cats: 10 patients (2004–2005)

AbstractObjective – To describe the use of continuous electroencephalographic (EEG) monitoring for management of status epilepticus (SE) in dogs and cats.Design – Retrospective study.Setting – University teaching hospital.Animals – Ten patients (7 dogs, 3 cats) with SE of differing etiology (idiopathic epilepsy, n=3; toxicity, n=4; meningoencephalitis, n=2; undefined, n=1).Interventions – The EEG was recorded continuously from 5 stainless‐steel needle electrodes inserted SC. Animals were treated with diazepam and phenobarbital followed by either propofol (n=3) or pentobarbital (n=7) as a continuous rate of infusion.Measurements and Main Results – Clinical seizures stopped after induction of anesthesia in each animal. The EEG, however, still showed distinct epileptiform patterns (spikes, polyspikes) in all animals. Paroxysms were suppressed by increasing the infusion rate of either pentobarbital or propofol. A burst‐suppression pattern was achieved in 5 animals. EEG epileptiform activity reappeared in 4 animals when attempting to taper the dose after &gt;6 hours of anesthesia. This was interpreted as ongoing EEG seizure activity and an increased risk for clinical seizures, and the anesthetic dosage was adjusted accordingly.Conclusion – Continuous EEG monitoring appears to be a useful tool for therapeutic monitoring of SE in dogs and cats. It allows the detection of EEG seizures without the appearance of clinical seizures. Further investigations with blinded investigators and homogeneous animal groups to define therapeutic endpoints are warranted.

Is the current management of status epilepticus in children safe and user friendly? A survey of healthcare professionals

ObjectiveStatus epilepticus is a medical emergency with significant morbidity and mortality. Treatment strategies include the use of licensed and unlicensed drugs. A short survey was conducted among specialist staff to...