Status epilepticus

Continuous vs. spot EEG
In a review of 7,102,399 critically ill patients from the Nationwide Inpatient Sample, the use of cEEG was associated with reduced in-hospital mortality (aOR 0.83, 95% CI 0.75-0.93), primarily for patients with subarachnoid or intraparenchymal hemorrhage or those with altered consciousness, but not for those with seizures or status epilepticus. This may, however, be an epiphenomenon as despite the authors efforts to control for them, characteristics of hospitals themselves that have cEEG available and use it often may improve their outcomes, not the cEEG itself. The use of cEEG was associated with increased hospital cost (aOR 1.17, 95% CI 1.11-1.23) and longer length of stay (aOR 1.11, 95% CI 1.08-1.13).

Seizure risk in inpatients
=== 2HELPS2B score === a Excluding generalized rhythmic delta b LPD = lateralized period discharges, BIPD = bilateral independent periodic discharges, LRDA = lateralized rhythmic delta activity If a seizure is detected at any time during monitoring, continue cEEG monitoring for at least 24 hours after last seizure.

Benzodiazepines
All patients with generalized convulsive status epilepticus should be treated with benzodiazepines within 20 minutes of hospital arrival. This is a Neurocritical Care Society Clinical Performance Measure.

Anticonvulsants
Treatment with either levetiracetam 60 mg/kg IV, fosphenytoin 20 mgPE/kg IV, or valproic acid 40 mg/kg IV are all reasonable as trial data suggests equivalent efficacy and safety. The Established Status Epilepticus Treatment Trial (ESETT) randomized 384 patients with benzodiazepine-refractory status epilepticus to levetiracetam (60 mg/kg, max 4500 mg), fosphenytoin (20 mgPE/kg, max 1500 mgPE), or valproic acid (40 mg/kg, max 3000 mg). All drugs led to seizure cessation and improved alertness by 60 minutes in approximately half the patients, and had similar adverse events.

All patients with generalized convulsive status epilepticus should be treated with a non-benzodiazepine AED within 40 minutes of hospital arrival. This is a Neurocritical Care Society Clinical Performance Measure.

Fosphenytoin
The aforementioned ESETT trial showed equivalence of fosphenytoin 20 mgPE/kg up to max 1500 mgPE to valproic acid and levetiracetam for treatment of status epilepticus.

Levetiracetam
The aforementioned ESETT trial showed equivalence of levetiracetam 60 mg/kg up to max 4500 mg to fosphenytoin and valproic acid for treatment of status epilepticus.

Levetiracetam can be administered safely in an undiluted form (100 mg/mL) at doses of ≤1000 mg IV over 2-5 minutes without injection site reactions or other clear side effects.

Valproic acid
The aforementioned ESETT trial showed equivalence of valproic acid (40 mg/kg, max 3000 mg) to fosphenytoin and levetiracetam for treatment of status epilepticus.

Without IV access
An as yet unpublished study from Germany of 42 patients with status epilepticus showed that 57% of them responded to intranasal midazolam.

Ketogenic diet
Although at high risk for publication bias, a review in 2013 noted 32 published cases of ketogenic diet used for children and adults, 78% of whom became seizure free, usually within 7-10 days of diet initiation.

In one series of 14 pediatric patients with convulsive refractory status epilepticus, 10 of 14 patients (71%) achieved seizure resolution within seven days after starting a ketogenic diet, and 11 of 14 patients (79%) were able to have continuous IV infusions within 14 days of starting the ketogenic diet.

Systems of care
We need to teach all physicians to give proper doses of AEDs and to think about the airway in status epilepticus. Neurology residents need to focus more on vitals signs, and other physicians need to focus more on administering second-line AEDs when needed. In a simulation study of 58 resident physicians (mix of intensive care medicine, internal medicine, neurology, and emergency medicine physicians) at the University Hospital Basel, the following problems were noted:
 * Airway management:
 * Physicians only checked the airway in 54% of patients and only protected them in 16% of patients.
 * Vital signs checks:
 * Neurology residents were less likely (OR 0.2, 95% CI 0.04-0.93) and internal medicine residents were more likely (OR 3.7, 95% CI 1.15-12.0) to check vital signs
 * First line AED dosage
 * Physicians only gave initial doses in line with guidelines in 19% of cases
 * Second line AED administration
 * Only 57% of physicians administered a second line AED.
 * Neurology residents were more likely (OR 5.0, 95% CI 1.01-25.3) to administer a second-line AED than other specialties