Management of the adult

Seek expert guidance and consult local guidelines.

The protocol for treating convulsive status epilepticus in adults is as follows:

• 1st stage (0-10 minutes) - early status:
  • ABC - maintain airway, ensure breathing, cardiovascular resuscitation if necessary
  • always give oxygen to prevent hypoxia
  • assess cardiorespiratory function
  • establish intravenous access
• 2nd stage (0-30 min):
  • institute regular monitoring
  • neurological observations
  • measurements of pulse, blood pressure, temperature
  • ECG, biochemistry, blood gases, clotting, blood count, drug levels
  • emergency investigations aimed at determining the cause of the epilepsy
  • hydration should be maintained with an intravenous infusion
  • give emergency anticonvulsant medication (AED) (see section: drug regimen for details of anticonvulsant management)
  • in suspected alcohol abuse or impaired nutrition administer
    • glucose (50 ml of 50% solution) and/or intravenous thiamine (250 mg) as high potency intravenous Pabrinex
  • treat acidosis if severe
• 3rd stage management (0-60 minutes) - established status:
  • determine the cause of the epilepsy:
    • consider MRI/CT scan
    • lumbar puncture may be required but care must be taken that intracranial pressure is not raised and facilities for resuscitation should be available
    • if stopping anticonvulsant treatment has precipitated status then the drug should be restarted
  • alert anesthetist and ITU
  • treat the complications of status, often hypotension necessitates the use of intravenous dopamine infusions
  • continue anticonvulsant medication
• 4th stage management (60-90 minutes) - refractory status:
  • if seizures continue despite the above measures then the patient should be transferred to intensive care where they should be ventilated and anaesthetised
  • aim for burst suppression on continuous EEG monitoring
  • continuous intracranial pressure monitoring may be required
  • longterm anticonvulsant medication is given in addition to the general anaesthetic agents (1)

References:

• (1) National Clinical Guideline Centre (NCGC) 2012. The Epilepsies. The diagnosis and management of the epilepsies in adults and children in primary and secondary care.