Treatment Of Status Epilepticus Research Articles

Sex-based analysis of status epilepticus management and outcome: A cohort study.

Status epilepticus (SE) is a neurological emergency with significant morbidity and mortality. The role of sex as a factor influencing the characteristics, treatment, and outcomes of SE has been scarcely addressed. This study investigates this variable regarding the clinical management and outcome among adult patients with SE. We retrospectively analyzed the Centre Hospitalier Universitaire Vaudois (CHUV) Status Epilepticus Registry (SERCH) over a 10-year period, including 961 SE episodes in 831 patients (56.82% male; 43.18% female), excluding post-axonic cases. There were no statistically significant differences in age, potentially fatal etiology, or pre-treatment consciousness impairment between sexes. Male patients were slightly younger (mean age 61 vs 64 years, p =.03), had a higher prevalence of prior seizures (54.76% vs 47.9%, p = .04), and were more likely to present with generalized convulsive SE (51.5% vs 41%), whereas female patients exhibited a higher frequency of focal unaware SE (31.7% vs 22.1%, global p = .02). Treatment strategies were similar across sexes, with benzodiazepines as first-line therapy in over 80% of cases, levetiracetam being the most frequently prescribed second-line treatment, followed by valproate and lacosamide. Development of refractory SE was comparable between sexes (54% in both, p = .92); outcomes at discharge were also similar. SE refractoriness and return to baseline conditions remained similar after multivariable adjustment for potential confounders. Overall, our results suggest comparable SE management, treatment responsiveness and outcomes between men and women.

Ketogenic diet treatment for super-refractory status epilepticus in the intensive care unit: feasibility, safety and effectiveness

Background and aimsTo investigate the feasibility, safety and effectiveness of the ketogenic diet (KD) for super-refractory status epilepticus (SRSE) in the intensive care unit (ICU).MethodsWe conducted a prospective investigation on patients with SRSE treated with the KD. The primary outcome measures were ketosis development as a biomarker of feasibility and resolution of SRSE as effectiveness. KD-related side effects were also investigated.ResultsTwelve patients (9 females and 3 males) with SRSE, with a median age of 34 years [range 16–69, interquartile range (IQR) 18–52], were treated with a KD. The median duration of SRSE prior to KD treatment was 21 days (range 4–46). SRSE resolved in 75% (9/12) of patients at a median of 3 days (range 1–18) after KD initiation. Among the nine KD responders, all were successfully weaned off anesthetic agents at a median of 16 days (range 4–32) after KD initiation, and all were also successfully weaned off ventilator. Side effects varied, and included gastrointestinal intolerances, malnutrition and metabolic abnormalities, electrolyte disturbance, and acute weight loss, although most of them could be corrected. No patient died due to KD, and neurofunctions continued to improve under KD therapy.ConclusionThe KD may be feasible and effective for the treatment of SRSE in the ICU. Moreover, it is relatively safe. However, there are numerous adverse events that can be corrected under close monitoring.

Effects of baicalein pre-treatment on the NLRP3/GSDMD pyroptosis pathway and neuronal injury in pilocarpine-induced status epilepticus in the mice.

Status epilepticus (SE) links to high mortality and morbidity. Considering the neuroprotective property of baicalein (BA), we investigated its effects on post-SE neuronal injury via the NLRP3/GSDMD pathway. Mice were subjected to SE modeling and BA interference, with seizure severity and learning and memory abilities evaluated. The histological changes, neurological injury and neuron-specific enolase (NSE)-positive cell number in hippocampal CA1 region, and cell death were assessed. Levels of the NOD-, LRR-, and pyrin domain-containing 3 (NLRP3)/gasdermin-D (GSDMD) pathway-related proteins, inflammatory factors, and Iba-1+NLRP3+ and Iba-1+GSDMD-N+ cells were determined. BA ameliorated post-SE cognitive dysfunction and neuronal injury in mice, as evidenced by shortened escape latency, increased number of crossing the target quadrant within 60 s and the time staying in the target quadrant, alleviated hippocampal damage, increased viable cell number, decreased neuronal injury, and increased NSE-positive cells. Mechanistically, BA repressed microglial pyroptosis, reduced inflammatory factor release, and attenuated neuronal injury by inhibiting the NLRP3/GSDMD pathway. The NLRP3 inhibitor exerted similar effects as BA on SE mice, while the NLRP3 activator partially reversed BA-improved post-SE neuronal injury in mice. Conjointly, BA reduced microglial pyroptosis in hippocampal CA1 area by inhibiting the NLRP3/GSDMD pyroptosis pathway, thereby ameliorating post-SE neuronal injury in mice.Significance Statement This study highlights the ameliorative role of BA in neuronal injury via repression of the NLRP3/GSDMD pyroptosis pathway in SE mice, offering theoretical support for the treatment of SE using BA.

A Study on Factors Causing Prehospital Delay in Treatment of Status Epilepticus.

To identify factors causing prehospital delay in treatment of status epilepticus (SE). This is a prospective observational study done on 78 patients with SE in the Stanley Medical College, Chennai, over 2 years. Demographic SE-related data and treatment delay were entered and correlated with outcome. The delay in reaching tertiary care was more in patients who traveled by own vehicle, compared to emergency medical services (EMS). Only 4 patients (5.1%) received treatment at the onset site and only seven patients (9%) who traveled in EMS received antiepileptic drugs. There is a significant delay in reaching the tertiary center from the onset of seizures if the patient is taken to any health center before coming to tertiary center (132.352 minutes). All the patients who were taken to another health center before reaching the tertiary center had received their initial treatment and favorable outcomes. Patients with prior history of seizures or SE had a better outcome. Early recognition of SE is necessary to initiate rapid treatment, preferably during the prehospital phase. EMS personnel should be prepared to treat SE promptly with the recommended first-line drugs.

Association of early general anesthesia with outcome in adults with status epilepticus: A propensity-matched observational study.

General anesthesia (GA) earlier than recommended (as first- or second-line treatment) was recently described to improve status epilepticus (SE) outcome. We aimed to assess the impact of early GA on outcome in matched groups. Data from a multicenter, prospective cohort of 1179 SE episodes in 1049 adults were retrospectively analyzed. Incident SE episodes were categorized as "early anesthesia" (eGA; GA as first- or second-line treatment) or "non-early anesthesia" (neGA; GA after second-line treatment or not at all). Using propensity score matching, eGA episodes were paired 1:4 with neGA episodes. We assessed survival, functional outcomes at discharge (good: modified Rankin Scale = 0-2 or no worsening), SE cessation rate, SE duration, and hospital stay. Among 1049 SE episodes, 55 (5.2%) received eGA, and 994 constituted the neGA group; 220 represented the matched controls. Patients receiving eGA were younger (median = 63, interquartile range [IQR] = 56-76 vs. median = 70, IQR = 54-80 years, p = .004), had deeper consciousness impairment (80% vs. 40% stuporous/comatose, p < .001), and had more severe SE forms (89% vs. 54% generalized convulsive SE/nonconvulsive SE in coma, p < .001). Mortality, functional outcome, SE cessation rate, and duration of SE and hospital stay were similar between the eGA group and matched controls. We conclude that early anesthesia for SE treatment did not influence prognosis.

Epileptiform Electrographic Patterns After Cardiac Arrest

This Viewpoint challenges conventional clinical practice that eschews pharmacological intervention for comatose patients with epileptiform abnormalities after cardiac arrest using evidence from the Treatment of Electroencephalographic Status Epilepticus after Cardiopulmonary Resuscitation (TELSTAR) trial.

Clinical Effectiveness and Safety of Midazolam Compared With Lorazepam for Control of Seizures in Adults

What Is the Issue? The emergency treatment of prolonged seizures or status epilepticus is required to be rapid and efficient to prevent permanent brain damage or death. Benzodiazepines, such as midazolam, lorazepam, diazepam, and clonazepam, are established as first-line treatment medications for acute treatments of seizures. Various administration routes of delivery for these drugs have become available, but the comparative clinical effectiveness and safety among administration routes are still unclear. Decision-makers are interested in whether the current use of intramuscular (IM) midazolam for treatment of seizures by paramedics in a prehospital environment can be switched to IV lorazepam as normally used by nurses and physicians in clinic settings. What Did We Do? We identified and summarized the literature on the evidence of the clinical effectiveness and safety of midazolam compared to lorazepam in adults to control seizures. We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2019. One reviewer screened citations for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings. What Did We Find? We identified 1 systematic review (SR) that included 4 randomized controlled trials (RCTs), only 1 was relevant to this review. This double-blind RCT determined the efficacy of IM midazolam as noninferior to IV lorazepam for treatment of seizures by paramedics in a mixed population of adults (89%) and children (11%). The authors of the SR conducted a subanalysis of a dataset of participant-level data and showed that IM midazolam was as effective and safe as IV lorazepam in adult patients for prehospital seizure cessation. The findings of the adult population were similar to those of the whole randomized population of both adults and children. What Does This Mean? With the shorter time required to administration of midazolam by the IM route compared to administration of lorazepam by the IV route, and the comparable efficacy and safety between the 2 active treatments, the use of IM midazolam may be a better option in the prehospital environment when IV access in patients with seizures is not readily established. Switching of IM midazolam to IV lorazepam for treatment of seizures by paramedics may not be practical.

Efficacy of Low-Dose Ketamine and Propofol in the Treatment of Experimental Refractory Status Epilepticus on Male Rats.

Refractory status epilepticus (RSE) is a condition with serious mortality and morbidity rate, resistant to benzodiazepine and second-line antiepileptic drugs. This study aimed to electrophysiologically investigate the combination of NMDA receptor antagonist ketamine and GABAergic agent propofol in an RSE model induced by lithium-pilocarpine in male Sprague-Dawley rats. Seventy-two male Sprague-Dawley rats were divided into nine groups. The RSE model was induced by subcutaneous injection of lithium-CI (5 mEq/kg) and intraperitoneal injection of pilocarpine-HCl (320 mg/kg), after implanting tripolar EEG electrode. Ketamine (30, 60, and 90 mg/kg), propofol (20, 40, and 80 mg/kg), and combinations of both drugs (15 + 20 and 30 + 40 mg/kg) were administered intraperitoneally to animals with RSE. Video-EEG recordings were taken after inducing model and 48 h later. The efficacy of drugs was statistically evaluated based on spike frequencies (spikes/min) and amplitudes (mV). Compared to RSE group, it was determined that 30 and 60 mg/kg doses of ketamine provided effective seizure control and prevented mortality (p < 0.001), while the 90 mg/kg showed toxic effects in all animals and caused mortality. The 80 mg/kg dose of propofol provided seizure control and reduced the mortality rate to 16.7% (p < 0.001), whereas the 20 mg/kg resulted in a 100% mortality rate. The low-dose ketamine+propofol (15 + 20 mg/kg) combination provided early onset seizure control and were as effective as 80 mg/kg propofol (p < 0.05). The study concluded that in the experimental RSE model, seizure control could be achieved with low-dose combination of ketamine and propofol without the need for high doses as in monotherapy, thus preventing dose-related adverse effects.

Impacto asistencial de la electroencefalografía realizada durante la guardia de Neurofisiología Clínica en un hospital de tercer nivel

IntroductionThe electroencephalogram (EEG) is a useful tool in the diagnosis of pathologies such as non-convulsive status epilepticus (NCSE) or brain death (BD), cardiac arrest (CA), and status epilepticus (SE) treatment monitoring. In addition, it provides irreplaceable information depending on the time it is performed, as is the case with the diagnosis of epilepsy after a first epileptic seizure (ES) or to differentiate these from non-epileptic paroxysmal events (NEPE). Its usefulness is maintained outside the usual working day, but it is not available in many centers. Subjects and methodsRetrospective observational study based on the clinical history of 86 patients who underwent an on-call EEG (ocEEG) at our hospital during 2020. ResultsOne hundred two records requested by Intensive Care (41.1%), Neurology (37.3%), Pediatrics (17.6%) or other services (4%) were made. Suspected NCSE represented 56.7%, followed by treatment monitoring in EE (21.6%). The ME accounted for only 6.9% of the total. The ocEEG avoided potential iatrogenesis in a 56.3% of cases with therapeutic implications, allowed to treat 27.58% of patients who would have remained without treatment until the conventional EEG. An increase in the level of care was required in only 22.2% of all cases. The ocEEG was anticipated a mean of 31.6h to the next conventional EEG that would have been available. ConclusionsThe availability of ocEEG is beneficial in terms of diagnosis, therapy, and hospital management, advancing decision-making and avoiding iatrogenesis. Its availability should become widespread.

Lack of association of first and second-line medication dosing and progression to refractory status epilepticus in children

PurposeEvaluate the relationship between first and second-line medication dosing and progression to refractory status epilepticus (RSE) in children. MethodsThis is a retrospective analysis of prospectively collected data from September 2014 to February 2020 of children with status epilepticus (SE) who received at least two antiseizure medications (ASMs). We evaluated the risk of developing RSE after receiving a low total benzodiazepine dose (lower than 100 % of the minimum recommended dose for each benzodiazepine dose administered within 10 min) and a low first non-benzodiazepine ASM dose (lower than 100 % of the minimum recommended dose of non-benzodiazepine ASM given as the first single-dose) using a logistic regression model, adjusting for confounders such as time to ASMs. The proportion of patients receiving low first non-benzodiazepine ASM doses was calculated and a logistic regression model was used to evaluate risk factors for low dosing of the first non-benzodiazepine ASM. ResultsAmong 320 children, 170 (53.1 %) developed RSE, and 150 (46.9 %) responded to the first non-benzodiazepine ASM dose (non-RSE). One hundred thirty-seven (42.8 %) received a low total benzodiazepine dose, and 128 (40 %) received a low first non-benzodiazepine ASM dose. The odds of developing RSE were not higher after a low total benzodiazepine dose (OR=0.76, 95 %CI 0.47–1.23, p = 0.27) or low first non-benzodiazepine ASM dose (OR=0.85, 95 %CI 0.42–1.71, p = 0.65). Receiving a low first non-benzodiazepine ASM dose was independently associated with having received a low total benzodiazepine dose (OR=1.65, 95 %CI 1.01–2.70, p = 0.04). ConclusionFor most patients, dosing variability in first and second-line medications for SE was not the sole clinical feature predicting progression to RSE in this cohort of benzodiazepine-resistant patients. Identification of additional modifiable clinical biomarkers that predict progression to RSE is needed. Though lower ASM doses did not predict RSE in this model, the administration of ASMs at doses likely to prevent RSE remains crucial in SE treatment.

Effectiveness and safety of Perampanel in refractory status epilepticus: a case series.

Perampanel is a selective non-competitive antagonist of AMPA receptors, and the first agent of this class to become available for the treatment of epilepsy. It could be a useful tool for treatment of refractory status epilepticus (RSE). We describe a series of eight RSE cases treated with Perampanel. Perampanel was successful in terminating SE in all the described cases. Only in one patient a severe psychomotor agitation occurred, but without needing PER discontinuation. No other adverse events were observed. Our case series of eight patients, albeit small, broadens the clinical experiences on the efficacy and safety of PER as a treatment for RSE. It may also support the early use of PER, considering the role of AMPA receptors in sustaining epileptic firing in SE. Further studies are warranted to clarify the potential of Perampanel in the treatment of status epilepticus and, in particular, in RSE.

Stiripentol for the treatment of refractory status epilepticus

BackgroundStatus epilepticus (SE) is one of the most common neurological emergencies and an acutely life-threatening condition characterized by high mortality and morbidity. Despite the well-established staged therapy of status epilepticus, especially stages 1 and 2, more than one third of patients develop (super-) refractory SE. Despite a large variety of potential treatment options for super-refractory SE, there is an unmet clinical need of potential new treatment ideas in this often desperate clinical situation.A number of studies have demonstrated the safety and efficacy of stiripentol (STP) in patients with Dravet syndrome (DS) and in children with focal epilepsy and generalized epilepsies. Some smaller series and case reports have documented the use of STP in the treatment of status epilepticus in adult patients.MethodsWe retrospectively analyzed all patients who were admitted to the Department of Neurology at Marburg University Hospital between 2013 and 2023 with a diagnosis of (super)-refractory status epilepticus and who received additional treatment of SE with STP. All patients who received STP during the SE were included, regardless of previous medication.ResultsSE ceased in 64% of 25 patients (13 female and 12 male). The mean age was 58.6 ± 21.9 years (mean ± SD). 72% had a structural epilepsy. In 20% of patients, SE was terminated by the administration of STP alone in 32% of cases, while in a further 32% of patients, the simultaneous administration of multiple anti-seizure medications (ASMs) including STP was potentially responsible for the cessation of the SE, with valproic acid (VPA), benzodiazepines and STP, being the most frequently implicated ASMs. In 12% of patients, there was at least a temporary improvement in the electroencephalogram (EEG). Stiripentol had to be discontinued in three cases due to a reduction in vigilance or hypercalcemia.ConclusionsStiripentol may represent a promising additional treatment option for refractory and super-refractory status epilepticus. The tolerability of this treatment has already been demonstrated in previous studies, and was also reflected in these data. Further prospective investigation in larger patient populations are necessary to ascertain the efficacy of stiripentol in SE.Trial registrationNCT06540378, retrospectively registered.

Ketamine plus midazolam compared to midazolam infusion for the management of refractory status epilepticus

BackgroundData for the use of ketamine (Ket) in treatment of refractory and super-refractory status epilepticus (RSE, SRSE) is lacking despite its widespread growing use. We examined the efficacy of ketamine plus midazolam (MDZ) infusions for treating RSE versus midazolam alone. We hypothesized that ketamine initiation would result in earlier seizure termination. MethodsData was obtained from electronic health records (EHR) of adult patients who received intravenous anesthetic agents for RSE in our neurointensive care unit. Two cohorts were identified. The MDZ cohort received midazolam as the only intravenous anesthetic agent for RSE. The Ket+MDZ cohort received midazolam infusion followed by ketamine infusion. The primary outcomes were time from midazolam infusion start to SE end in both cohorts, and time from ketamine infusion start (Ket Start) to SE end in the Ket+MDZ cohort versus midazolam infusion start (MDZ start) to SE end in the MDZ cohort. Results73 patients were included (MDZ cohort n=17, Ket + MDZ cohort n=56). Cohorts did not differ significantly in age, sex, race, RSE etiology, or GCS on admission. Mean APACHE II score was higher in the Ket +MDZ cohort (26 ± 7.32 SD) versus the MDZ cohort (22 ± 5.89 SD)(P=.015). In survival analyses, cohorts did not differ significantly in time from midazolam start to SE end (HR=0.965, 95 % CI=0.556–1.673, P=.899; median [IQR]: MDZ: 25 h [4.5–58]; Ket+MDZ: 21.5 h [IQR 13.5–49]). Time from Ket start (Ket+MDZ group) versus time from MDZ start (MDZ group) to SE end was significantly shorter in the Ket+MDZ cohort (HR=1.895, 95 % CI=1.083–3.314, P=.025). The pattern of results was similar when including APACHE II and MDZ maximum dosage as covariates. ConclusionTime to SE end was significantly shorter after addition of ketamine infusion to midazolam infusion, versus after initiation of midazolam infusion monotherapy. Patients with higher disease severity favored Ket+MDZ. Randomized controlled trials are warranted in determining optimal anesthetics in RSE and SRSE.

Use Of Ketamine In Refractory Status Epilepticus With Hemodynamic Instability

The use of benzodiazepines, such as midazolam, as a last-resort treatment for refractory status epilepticus is widely practiced, particularly in patients who are hemodynamically stable. However, as the dosage of this antiepileptic agent is increased, it potentiates γ-aminobutyric acid (GABA) activity, which can lead to hypotension and subsequently necessitate the administration of vasopressor agents, especially in cases involving hemodynamic instability, as illustrated by this case where a young man who arrived at the emergency department with complaints of epileptic seizures and was already on regular anti-epileptic medications. During a seizure episode in the department, he was administered intravenous Lorazepam according to standard protocol to stop the seizure, and then placed on an IV infusion of Midazolam. However, his hemodynamics became unstable due to the side effects of the benzodiazepines administered. To address this instability, the decision was made to initiate an infusion of Ketamine along with a low dose of Midazolam. This combination successfully terminated the epileptic activity and stabilized his hemodynamics. In these instances, either concurrent or standalone administration of N-methyl-D-aspartate (NMDA) receptor antagonists might prove beneficial for managing refractory status epilepticus. For example, ketamine infusion can inhibit the reuptake of catecholamines into the systemic circulation, thereby aiding in the maintenance of blood pressure in hemodynamically unstable patients. The initial application of a combined third-line therapy, which involves blocking NMDA receptors while simultaneously enhancing GABAergic activity, appears promising for the management of refractory status epilepticus

A systematic review and meta-analysis of ketamine in pediatric status epilepticus.

Status epilepticus (SE) is a common neurological medical emergency in the pediatric population, with 10%-40% of cases progressing to refractory SE (RSE), requiring treatment with anesthetic infusions. We present a systematic review and meta-analysis of the use of ketamine for the treatment of pediatric SE and its potential advantages over other anesthetic infusions. This review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Electronic databases, including PubMed, Cochrane Library, Ovid, Embase, and Google Scholar, were searched with the keywords "pediatrics," "status epilepticus," and "ketamine treatment." Randomized trials, prospective and retrospective cohort studies, and case reports were considered for inclusion. Eighteen publications met the initial inclusion criteria. The 18 publications comprise 11 case reports, one nonconclusive clinical trial, two case series, and four retrospective cohorts. After excluding the case reports because of reporting bias, only the six case series and cohorts were included in the final analysis. There were 172 patients in the six included studies. The weighted age was 9.93 (SD = 10.29) years. The weighted maximum dose was 7.44 (SD = 9.39) mg/kg/h. SE cessation was attained in 51% (95% confidence interval = 43-59) of cases with the addition of ketamine. The heterogeneity was I2 = 0%, t2 = 0, χ2 (5) = 3.39 (p = .64). Pediatric RSE is difficult to treat, resulting in increased morbidity and mortality. Without strong recommendations and evidence regarding preferred agents, this review provides evidence that ketamine may be considered in managing SE in the pediatric population.

Intravenous levetiracetam versus intravenous phenytoin as second Line treatment in pediatric convulsive status epilepticus- open label randomized controlled trial.

Benzodiazepines (BZDs) are recommended as the initial therapy of choice in status epilepticus (SE). The age-old second-line treatment for BZD refractory convulsive SE is intravenous phenytoin (PHT) based predominantly on nonrandomized clinical trial data. We did this study to compare the efficacy and safety of intravenous levetiracetam (LEV) and PHT as second-line antiseizure medication (ASM) for children with SE. A prospective, randomized controlled, open-label study was conducted in children 3 months to 15 years of age with SE in Pediatric Emergency. A total of 41 children were randomly allocated to either group 1 (Levetiracetam) or group 2 (Phenytoin) on the basis of computer-generated randomization. Children who were already on antiseizure medications, either LEV or PHT, or receiving these drugs outside for SE were excluded. Data analysis was done by SPSS V25. The most common age group presenting with SE was 12 months to 5 years. Clinical cessation of seizure 5 minutes after the completion of drugs was 85% (17/20) in Levetiracetam group and 90.5% (19/21) in Phenytoin group. Recurrence of seizure within 24 hours was noted in 35% (7/20) in Levetiracetam group and 38.1% (8/21) in Phenytoin group. There was no statistically significant difference noted in both the groups in terms of seizure cessation, adverse events, and recurrence. The efficacy and safety of LEV were found to be comparable to those of PHT in controlling seizure as second-line ASM in SE.

Improving Quality of Care for Status Epilepticus: Putting Protocols into Practice.

Timely treatment of status epilepticus (SE) improves outcomes, however gaps between recommended and implemented care are common. This review analyzes obstacles and explores interventions to optimize effective, evidence-based treatment of SE. Seizure action plans, rescue medications, and noninvasive wearables with seizure detection capabilities can facilitate early intervention for prolonged seizures in the home and school. In the field, standardized EMS protocols, EMS education, and screening tools can address variability in SE definitions and treatment, particularly benzodiazepine dosing. In the emergency room and hospital, provider education, SE order sets and alerts, and rapid EEG technologies, can shorten time to first-line therapy, second-line therapy, and EEG initiation. Widespread, sustained improvement in SE care remains challenging. A multipronged approach including emphasis on pre-hospital intervention, treatment protocols adapted to local contexts, and SE databases to systematically collect process and outcome metrics have the potential to transform SE treatment and outcomes.

Can Bispectral Index be Used in the Diagnosis and Treatment of Non-convulsive Status Epilepticus in Children?

Can Bispectral Index be Used in the Diagnosis and Treatment of Non-convulsive Status Epilepticus in Children?

Emergency Approach to Acute Seizures in Dogs and Cats.

Seizures are a common presentation seen in small animal practices. Seizures require prompt management including initial interventions for triage, stabilization, and treatment with first-line anticonvulsant (AC) drugs like benzodiazepines. Concurrently, ruling out metabolic or extracranial causes with point-of-care diagnostics can help guide further diagnostics and treatments. Analysis of the history and a physical exam are also necessary to rule out common "look-alikes" that require specific diagnostic workup and treatments. Typically, causes of seizures can be grouped into intracranial and extracranial causes, with the latter being easier to diagnose with commonly available tests. This review presents a systematic approach to the diagnosis and treatment of single seizures, cluster seizures, and status epilepticus in dogs and cats.

Challenges of status epilepticus management in a resource-limited setting: A review

Status epilepticus (SE) is a life-threatening neurological condition with significant mortality. Rapid management is essential to minimize the mortality and disability of SE. Two recent trials provided evidence to guide SE management in early and established stages. The Rapid Anticonvulsant Medication Prior To Arrival Trial (RAMPART, 2011) showed that intramuscular midazolam is a better alternative for early convulsive SE in prehospital settings. The Established Status Epilepticus Treatment Trial (ESETT, 2020) supported the use of sodium valproate and levetiracetam as second-line treatment for its efficacy and shorter administration time. However, there are challenges to revising the status epilepticus management in resource-limited settings, in pre-hospital, first- and second-line treatment, as well as management of refractory and super-refractory SE. These challenges included restrictions or lack of training in the administration of benzodiazepine in the prehospital setting, limited availability and accessibility of newer antiseizure medications (ASMs) in emergency departments and smaller hospitals, and low clinicians’ awareness of the latest evidence. A collaborative effort to educate, improve awareness, and make certain ASMs more readily available is recommended to achieve a better clinical outcome in SE.