Today, after listening to the great podcast and reviewing the equally great Internet Book of Critical Care [Link is to the Table of Contents] chapter, Generalized Convulsive Status Epilepticus [Link is to the chapter and to the podcast] by Dr. Josh Farkas.
And the Resuscitation Crisis Manual, Chapter 22 is a great two page summary covering the same subject and this chapter is written by Dr. Farkas.
- Diagnosis & definition
- Questions & discussion
- PDF of this chapter (or create customized PDF)
Here are some excerpts:
Be sure and click on the above to review the list.
If after reviewing the above list, status epilepticus without an obvious cause? think NORSE
NORSE (new-onset refractory status epilepticus)
- Definition: Refractory status epilepticus without any readily identifiable cause (in a patient without prior seizures or structural neurologic disease).
- ~40% Non-paraneoplastic autoimmune (e.g. anti-NMDA encephalitis)
- ~30% Paraneoplastic
- ~20% Infectious
This algorithm [above] describes the approach to a convulsive generalized seizure lasting >5 minutes. For a patient with recurrent seizures who isn’t actively seizing, a more gradual approach may be taken (with escalation if an active seizure resumes).
The duration of time in which a patient can be in convulsive status epilepticus before brain damage occurs is unknown. Many experts estimate this to be around 30 minutes (30516601). Consequently, the above algorithm is designed to break nearly all seizures within 30 minutes. This requires rapid escalation to intubation.
- If patients can regain normal consciousness, they aren’t seizing.
- An inability to regain consciousness raises concern for persistent non-convulsive status epilepticus (NCSE).
video EEG (vEEG)
- Continuous vEEG is preferred (especially for more complex patients). For patients who don’t regain normal consciousness, intermittent seizures may be occurring which could be missed with a single “spot” EEG.
- There is no consensus or data regarding whether it is best to titrate medication to target burst-suppression or simply the absence of seizures.
- Targeting a deeper level of sedation (e.g. burst-suppression) will generally increase time on ventilation and medication-related complications.
- In the absence of clear evidence, simply targeting the absence of seizures may minimize iatrogenic harm.
- vEEG can lead to over-treatment and iatrogenic harm, if:
- (1) A decision is made to target burst-suppression or flat-line EEG for prolonged periods of time.
- (2) Efforts are made to suppress all ictal-spectrum patterns (e.g. periodic lateralizing epileptiform discharges).