QuestionSBA
QuestionChoice
This likely will be requested to detect any signs of a head injury given the lack of a history, however it is not the most important next step.
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d
CT scan of the head
QuestionChoice
This may be necessary as he is twitching which may represent seizure activity, but hypoglycaemia must be excluded first.
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c
Start phenytoin infusion
QuestionChoice
Seizures can be precipitated by hypoglycaemia, especially in patients at risk of malnutrition (such as this gentleman who is homeless and has a history of alcohol use). This should be done immediately.
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a
Measure capillary blood glucose
QuestionChoice
The patient has had 2 doses of a benzodiazepine (1 of midazolam and 1 of lorazepam). If he continues seizing and hypoglycaemia is excluded, he will require second line treatment (levetiracetam, phenytoin, or valproate)
10017357
b
Administer another dose of lorazepam
QuestionChoice
This may be necessary as he is twitching which may represent seizure activity, but hypoglycaemia must be excluded first.
10017360
e
Start levetiracetam infusion
Concept
Chapter
# Summary
 
Status epilepticus is defined as either continuous or recurrent seizure activity that lasts for more than 5 minutes. It can be convulsive or non-convulsive, with the latter form being more difficult to recognise. It is a medical emergency that can be fatal or lead to permanent neurological damage. Management follows an algorithm which involves early administration of anticonvulsants starting with benzodiazepines. Looking for reversible causes (e.g. hypoglycaemia) and ensuring that the seizure is timed to allow prompt drug administration are both important aspects of management. 
 

# Definition
 
Status epilepticus (SE) refers to a prolonged period of seizure activity of any time (i.e. convulsive or non-convulsive). **Established** SE is used to describe seizures lasting for 30 minutes or longer (without any episodes of complete recovery in between seizures), whereas in clinical practice any seizure activity which has not terminated within 5 minutes is considered SE.

# Aetiology

In one third of patients, SE is the first presentation of chronic epilepsy. 

One third of patients presenting with SE already have a known background of epilepsy - the following may trigger prolonged seizures:

- A withdrawal or change in antiepileptic medications
- Non-compliance with antiepileptic medications
- Seizure threshold-lowering medications (e.g. tramadol) 
- Intercurrent illness
- Metabolic abnormalities (e.g. hyponatraemia)

Another third of patients do not have epilepsy - the following may be factors causing seizures:

- Infection (e.g. cerebral abscess or encephalitis)
- Brain injury (e.g. trauma, stroke, subarachnoid haemorrhage)
- Withdrawal from drugs such as alcohol or benzodiazepines

# Signs and Symptoms

**Convulsive status epilepticus:**

- Abrupt generalised muscle stiffening (tonic phase) followed by rhythmic jerking of the muscles (clonic phase)
- Loss of consciousness
- Tongue biting - typically lateral tongue
- Urinary or faecal incontinence
- Clenched jaw
- Erratic eye movements
- Drooling
- Cyanosis

**Non-convulsive SE:**

- Reduced levels of consciousness
- Catatonia
- Behavioural changes/psychosis
- Subtle motor signs e.g. myoclonus, eye deviation or twitching
- Autonomic dysfunction
- Speech disturbance e.g. aphasia or perseveration

# Differential Diagnosis

The main differential for convulsive SE is **non-epileptic seizures** - these can be difficult to differentiate and may co-exist in patients with known epilepsy. Non-epileptic seizures typically last longer than epileptic seizures but often have the following features that would be atypical in a true seizure:

- Eyes closed
- Emotional vocalisations e.g. crying or screaming 
- Limbs moving in phase with each other
- Head and trunk moving side to side
- Pelvic thrusting
- React to external stimuli e.g. noises
- Incontinence and tongue biting rare

**Rigors** and **acute dystonic reactions** may also share some features of abnormal movements however they are usually distinguishable by the quality of the movements and the duration.

Non-convulsive SE has many differentials and EEG is often required to help with diagnostics - the following are some examples:

- Encephalitis 
- Hypoglycaemia
- Psychogenic pseudocoma
- Alcohol or benzodiazepine withdrawal
- Transient global amnesia
- Stroke

# Investigations
 
**Bedside tests:**

- **Capillary blood glucose** for hypoglycaemia
- **Blood gas** for electrolytes, lactate and acid-base status
- **Urine toxicology screen** if illicit drug use is suspected (may also test blood for this)
- **Pregnancy test** if woman of childbearing age as many antiepileptic medications are teratogenic
- **ECG** as some medications used require cardiac monitoring (e.g. phenytoin), may see other signs of triggers such as electrolyte imbalance or subarachnoid haemorrhage

**Blood tests:**

- **Full blood count and CRP** for inflammatory markers
- **U&Es, bone profile and magnesium** for electrolyte derangement
- **LFTs** as a baseline prior to starting anticonvulsant medications
**Clotting screen** as intracranial haemorrhage may be a trigger
- **Serum anticonvulsant levels** if on antiepileptic medications
- **Blood cultures** if febrile or other signs of septicaemia

**Imaging:**

- **CT head** may be done once patient stabilised if an intracranial cause is supected
- **Chest X-ray** once seizure terminated if signs or symptoms of aspiration

**Other tests:**

- **EEG** is not usually required acutely but can be useful e.g. in the diagnosis of suspected non-convulsive SE
- **Lumbar puncture** may be done after the patient is stabilised and seizures have terminated e.g. in suspected meningitis or subarachnoid haemorrhage

# Management
 
- As soon as a seizure is recognised, start a timer to time the seizure (crucial to ensure that medications are given on time and the patient is escalated appropriately)
- Ensure the patient is in a safe place and the head is protected (e.g. by putting padding around them)
- Insert an airway adjunct (e.g. nasopharyngeal airway) if safe to do so 
- Give high-flow oxygen via a non-rebreather mask
- Check glucose and correct hypoglycaemia if present (give Pabrinex first if any suspicion of alcohol excess or malnutrition)
- In cases of known epilepsy, check if the patient has a personalised emergency management plan - in most cases follow the below algorithm:
	- At **5 minutes** give 4 mg IV lorazepam (or rectal diazepam/buccal midazolam if no IV access)
	- At **10 minutes** repeat benzodiazepine as above
	- At **15 minutes** give an IV infusion of one of levetiracetam, phenytoin or valproate (if still no IV access gain intraosseous access)
	- If this is unsuccessful consider one of the other second-line treatments; phenobarbital is also an option
	- At **30 minutes** ongoing seizures are considered **refractory SE** which is treated with induction and maintenance of general anaesthesia (usually with propofol and/or midazolam)

Once the seizure has terminated:

- Reassess the patient to identify any complications (e.g. aspiration)
- Treat any identified underlying cause (e.g. intercurrent infection or electrolyte imbalance)
- Ensure appropriate antiepileptic medications are prescribed - neurology advice may be required 

**Note** - non-convulsive SE is treated with similar medications (e.g. benzodiazepines and anticonvulsants) but may be difficult to diagnose and so treatment is often delayed - see below references for further details.

# NICE Guidelines

[NICE - Treating Status Epilepticus](https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures)

[NICE CKS - Epilepsy](https://cks.nice.org.uk/topics/epilepsy/)

# References
 
[RCEM Learning - Status Epilepticus](https://www.rcemlearning.co.uk/reference/status-epilepticus/)

[Patient UK - Status Epilepticus Management](https://patient.info/doctor/status-epilepticus-management)

[Life in the Fast Lane - Differential Diagnosis of Seizures](https://litfl.com/seizures-ddx/)

[Life in the Fast Lane - Non-convulsive Status Epilepticus](https://litfl.com/non-convulsive-status-epilepticus-ncse/)
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Always measure capillary blood glucose in seizure patients, particularly those at risk of hypoglycaemia due to malnutrition or alcohol use.
A homeless man with no identification is conveyed to the emergency department by ambulance after suffering mutliple seizures. He has been given a dose of buccal midazolam and intravenous lorazepam with the ambulance service. He smells of alcohol and is intermittently twitching.

What is the most important next step?
a