Status epilepticus. Advances in the treatment.

Abstract

Status epilepticus is a major medical emergency that is fatal in 7.6-22% of cases. The incidence per 100,000 population has been estimated at 9.9 episodes in Europe and 41 episodes in the USA. Status epilepticus may be convulsive, i.e., accompanied by motor, activity, or nonconvulsive. There is a consensus that seizures lasting longer than 30 min. constitute established status epilepticus. A useful strategy focuses on imminent convulsive status epilepticus, defined as continuous seizures for longer than 5 min. or three seizures not separated by recovery of normal consciousness or of the level of consciousness present before the seizures. Members of an international workshop held by the Epilepsy Research Foundation agreed on a somewhat vague definition of non-convulsive status epilepticus as “a range of conditions in which electrographic seizure activity is prolonged and results in non-convulsive clinical symptoms”. The immediate treatment goals in patients with generalized convulsive status epilepticus are cessation of the clinical seizures and prevention of subtle status epilepticus. Intravenous lorazepam is the first-line treatment for generalized convulsive status epilepticus. If the seizure persists, a second injection can be given 10 minutes later. Phenytoin or fosphenytoin is a good choice when lorazepam fails. Administration of an additional lorazepam dose can be considered. Anesthesia with propofol, thiopental, or midazolam is the cornerstone of the management of refractory status epilepticus. Regardless of the drug used, the dose should be titrated at 3 to 5 min. intervals under EEG monitoring with the goal of obtaining a burst-suppression pattern with suppression for 5 to 10 seconds.