Status Epilepticus

Key Features

Essentials of Diagnosis

• Occurrence of two or more convulsions without recovery of consciousness between attacks

• A fixed and enduring epileptic condition (for 30 minutes or more)

General Considerations

• Status epilepticus is a medical emergency

• Causes

  • Poor compliance with the anticonvulsant drug (most common)

  • Alcohol withdrawal

  • Intracranial infection or neoplasms

  • Metabolic disorders

  • Drug overdose

• Mortality rate of status epilepticus may be as high as 20%, with a high incidence of neurologic and mental sequelae

• Prognosis relates to the length of time between onset of status epilepticus and start of effective treatment

Clinical Findings

Symptoms and Signs

• Two clinical subtypes

  • Convulsive (tonic-clonic) status epilepticus

  • Nonconvulsive status epilepticus, characterized by:

    • Two subtypes: absence (petit mal) and complex partial status epilepticus

    • Fluctuating abnormal mental status

    • Confusion

    • Impaired responsiveness

    • Automatism

Differential Diagnosis

• Seizure due to

  • Hypoglycemia

  • Electrolyte abnormality

  • Alcohol withdrawal

  • Cocaine

  • Bacterial meningitis

  • Herpes encephalitis

  • Brain neoplasm

  • CNS vasculitis

• Syncope

• Cardiac arrhythmia

• Brainstem ischemia

• Pseudoseizure

• Panic attack

• Rage attack

• Migraine

• Narcolepsy

Diagnosis

Laboratory Tests

• Electroencephalography is essential in establishing the diagnosis of nonconvulsive status epilepticus and its two subtypes (absence [petit mal] and complex partial status epilepticus)

Treatment

Medications

• See Table 24–2

• Initial treatment with intravenous lorazepam or midazolam is usually helpful regardless of the type of status epilepticus

• Phenytoin, carbamazepine, and other drugs may also be needed to obtain and maintain control in complex partial status epilepticus