Defined as continuous seizures (_15–30 min) or
repetitive, discrete seizures with
impaired consciousness in the interictal period. May
occur with all kinds of seizures: grand mal (tonic-clonic) status, myoclonic
status, petit mal status, and temporal lobe (complex partial) status.
Generalized, tonic-clonic seizures are most
common and are usually clinically obvious early in the
course. After 30–45 min,
the signs may become increasingly subtle and include only
mild clonic movements
of the fingers or fine, rapid movements of the eyes. In
some situations, EEG may
be the only method of diagnosis. Generalized status is
life-threatening when accompanied by hyperpyrexia, acidosis (from prolonged
muscle activity), respiratory or cardiovascular compromise. Irreversible
neuronal injury may occur from persistent seizures, even when pt is paralyzed
from neuromuscular blockade.
Etiology
Principal causes of tonic-clonic status are antiepileptic
drug withdrawal or noncompliance, metabolic disturbances, alcohol or drug
related, CNS infections,
CNS tumors, refractory epilepsy, cerebrovascular disease,
and head trauma.
TREATMENT
Generalized tonic-clonic status epilepticus is a medical
emergency. Pts must
be evaluated promptly and appropriate therapy instituted
without delay (Fig.
22-1). In parallel, it is essential to determine the
cause of the seizures to
prevent recurrence and treat any underlying
abnormalities.
1. Assess carefully for evidence of respiratory or
cardiovascular insufficiency.
Withcareful monitoring and standard airway protection,
pts usually
do not require intubation (if intubation is necessary,
use short-acting paralytics).
Treat hyperthermia. Establish IV and administer 50 mL 50%
dextrose
in water, 100 mg thiamine, and 0.4 mg naloxone.
2. Perform a brief medical and neurologic examination;
send samples
for laboratory studies aimed at identifying metabolic
abnormalities (CBC with
differential, serum electrolytes including calcium,
glucose, liver and renal
function tests, toxicology if indicated).
3. Administer lorazepam, 0.1 mg/kg (4–8 mg) at 2 mg/min.
4. Immediately after lorazepam, administer phenytoin, 20
mg/kg (1000–
1500 mg) IV slowly over 20 min (50 mg/min) or
fosphenytoin, 20 mg/kg
(150 mg/min). Monitor bp, ECG, and, if possible, EEG
during infusion.
Phenytoin can cause precipitous fall in bp if given too
quickly, especially in
elderly pts. (Do not administer phenytoin with 5%
dextrose in water—
phenytoin precipitates at low pH. This is not a problem
with fosphenytoin.)
If seizures are not controlled, a repeat bolus of
phenytoin (5–10 mg/kg) or
fosphenytoin (5–10 mg/kg) may be given.
5. If seizures persist, administer phenobarbital 20 mg/kg
(1000–1500 mg)
slowly over 30 min. Endotracheal intubation will often be
required by this stage.
If seizures continue, give additional dose of
phenobarbital (5–10 mg/kg).
6. If seizures remain refractory after 60–90 min,
consider placing pt in
midazolam, propofol, or pentobarbital coma. Consultation
witha neurologist
and anesthesiologist is advised.
Prognosis
The mortality rate is 20% in tonic-clonic status, and the
incidence of permanent
neurologic sequelae is 10–30%.
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