Status Epilepticus in the Emergency Department, Part 2: Treatment
In part 1 of this 2-part review, the authors detailed proper diagnosis of seizures in the ED setting. In this concluding article, they focus on appropriate management and treatment options for patients with seizure.
Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.
Dr Eisenstat is a senior resident in emergency medicine, University of Virginia School of Medicine, Charlottesville. Dr Huff is a professor of emergency medicine and neurology, and the director, medical student clerkship, University of Virginia School of Medicine, Charlottesville.
Status epilepticus is defined as continuous seizure activity for greater than 5 minutes, or repeated episodes of seizures without resolution of the postictal period. When the clinician arrives at the patient’s bedside or the emergency medical technician arrives at the scene in the prehospital setting, the patient may be minutes into seizure activity. If the seizure does not immediately resolve, the provider should treat as if status is imminent, if not ongoing. Regardless of setting, if the patient is discovered to be seizing, treatment should be initiated.
It is important to distinguish between provoked and unprovoked seizures, since successful management may require treating an underlying etiology. Although there are as many types of status epilepticus as there are types of seizures, the focus of this review is on generalized convulsive status epilepticus (GCSE).
As a GCSE continues, the overt seizure activity may become subtle—essentially a transformation of generalized status to a state with minimal or no motor movements. Whether or not there is an absence of, or minimal, movement, GCSE still represents a medical emergency, since the excessive neuronal activity causes neuronal injury. An electroencephalogram (EEG) may be required to detect transformed GCSE, which should be suspected if the patient does not exhibit improved mental status within 20 to 30 minutes of convulsive seizure cessation, or if neuromuscular paralysis for intubation has occurred.
Initial Management
Initial management of seizure patients is consistent with the care of any critical patient in the ED. Assessment of the airway and airway management with endotracheal intubation may be necessary for patients who are apneic or at risk for aspiration, or in whom more conservative management is inadequate.
While placing a patient in the left lateral decubitus position may mitigate aspiration risk, since vomiting is common in a postictal state, moving a convulsing patient may be challenging.1 Patients should be placed on cardiac monitoring with pulse oximetry if feasible. Intravenous (IV) access should be established if possible, though intramuscular (IM) or other alternative routes for benzodiazepines may be used if obtaining IV access will result in a delay in treatment.2
Oxygen should be administered via nonrebreather or bag-valve-mask to patients with apnea to prevent both systemic and cerebral hypoxia.3Since cardiac dysrhythmias with cerebral hypoxia may cause seizure-like activity, it is imperative to check the patient’s pulses, blood pressure, and to maintain cardiac monitoring during convulsive episodes.4 The patient’s glucose levels should be checked upon arrival to determine if the seizure is due to metabolic disturbance, which is an easily reversible cause of seizure. If glucose point-of-care testing is not available, it is reasonable to treat empirically for hypoglycemia.
