• This is medical emergency
• It is defined as continuous seizure for 5 minutes without regaining consciousness in between.
• Epilepsy is defined as a 2 or more spontaneous seizures without an obvious precipitating cause

Types

• Convulsive Status Epilepticus– Defined as sustained generalized tonic and clonic motor activity lasting for more than 5 minutes without return of consciousness
• Non Convulsive status Epilepticus- Defined as Status epilepticus without prominent motor symptoms

Etiology

• Infectious causes- Encephalitis, Meningitis
• Non Infectious – Congenital malformation, Metabolic abnormalities, Drug intoxication.

Evaluation

History

• Events in pre-ictal, ictal and post-ictal phase
• Duration of seizure
• Seizure characteristics
• Signs of head trauma
• Associated symptoms
• Prior history of epilepsy, compliance with antiepileptics medication
• History of neurological development abnormality

Examination

• GCS
• Neurological Assessment
• Signs of meningeal irritation
• Signs of infection

Investigations

• Full blood count
• C- reactive Protein
• Blood sugar random
• Serum Electrolytes
• Serum Calcium, Magnesium
• CSF
• Neuroimaging- CT/MRI Brain

Management Steps

• ABCD- Establish and secure airway, ensure patient is breathing and place patient in left lateral position
• Vitals monitored
• Identify and treat hypoglycemia
• Identify and treat life threatening causes of status epilepticus- Trauma, sepsis, meningitis, Encephlitis or structural brain lesion.
• Suction secretions if necessary
• Administer Oxygen
• IV access
• Administer IV Lorazepam or diazepam or Midazolam then reassess patient , If seizure persists then give second dose
• Reassess the patient if still having seizures, then give IV levetiracetam
• Emergency consultation with pediatric neurologist
• Give second antiepileptic medication –Phenytoin/fosphenytoin, sodium valproate
• If seizure persists then prepare for mechanical ventilator and continuous midazolam infusion, propofol or pentobarbital
• Monitor patient with continuous EEG
• Titrate infusion to electroclinical seizure suppression for 24-48 hours and then attempt slow wean.
• Paradoxical effects of antiseizure medication; Elevated levels of antiseizure medication including phenytoin, carbamazepine, gabapentin, tiagabine and vigabatrin can paradoxically trigger generalized convulsive status epilepticus particulary myoclonus type, as well as nonconvulsive type (Absence), when suspected , managed by benzodiazepines.
• Some antiseizure medications may worsen seizures caused by illicit drugs for example , phenytoin could worse the toxicity of lidocaine or cocaine
• Some antiseizure medications worsen other types of seizures; Carbamazepine worsen myoclonic seizures , drop attacks and patients with dravet syndrome, Phenytoin and lamotrigene worsen myoclonic seizure
• Refractory Status Epilepticus; Lacosamide and topiramate play a role in the management of refractory status. NORSE and FIRES account for only a small proportion of the refractory SE.
• NORSE and FIRES; New Onset Refractory Status Epilepticus (NORSE)– is characterized by absence of clear acute structural, toxic or metabolic cause for SE during the first 72 hours after presentation. Many cases have an inflammatory or autoimmune etiology. Febrile infection related epilepsy syndrome (FIRES) -refers to subtype of NORSE , with prodromal febrile illness between 2 weeks and 24 hours prior to onset of refractory SE. these will be managed with IV methyl prednisolone 20-30mg/kg/day for 3-5 days or IVIG 2G/kg over 2-5 days. KETOGENIC DIET should be started. Second line immunosuppressive therapy rituximab, tocilizumab or anakinra.