Status Epilepticus (SE)
Definition
Status epilepticus (SE) is a neurological emergency characterized by prolonged or recurrent seizures without full recovery of consciousness between events.
Classicication
Convulsive Status Epilepticus (CSE): Prolonged tonic-clonic seizures.
Non-Convulsive Status Epilepticus (NCSE): Altered consciousness with subtle motor or no apparent motor activity. The clinical threshold is 5 minutes for ongoing seizures or two or more seizures without regaining consciousness, as prolonged seizures increase the risk of neuronal injury and systemic complications. Seizures lasting more than 5 minutes are classified as early status epilepticus, those lasting over 30 minutes as established status epilepticus, and those persisting beyond 60 minutes as refractory status epilepticus.
Epidemiologi
10–40 cases per 100,000 people annually. Most common in young children and the elderly. The most prevalent cause of ES is febrile seizure. Status epilepticus (SE) is often associated with underlying conditions such as epilepsy, brain injuries, infections, or metabolic disturbances. It can manifest in various epileptic syndromes, including Dravet syndrome, Lennox-Gastaut syndrome, and others.
Clinical Features
Tonic-clonic convulsions lasting more than 5 minutes. Unresponsiveness during the seizure. Cyanosis, tachycardia, and other systemic effects due to prolonged motor activity. Non-convulsive status epilepticus (NCSE) manifests as subtle or absent motor symptoms.
Altered mental status: confusion, stupor, or coma. Often identified via EEG.
Triggers: Poor adherence to antiepileptic drugs in individuals with epilepsy, fever, stroke, trauma, brain tumors, and CNS infections (e.g., meningitis, encephalitis).
Metabolic abnormalities: Hypoglycemia, hyponatremia, alcohol or drug withdrawal.
Systemic complications: Respiratory failure, aspiration pneumonia, cardiac arrhythmias, hypertension, rhabdomyolysis and renal failure due to prolonged muscular spasms.
Diagnosis
Clinical criteria: Ongoing seizure activity lasting over 5 minutes is considered as early status epilepticus. Recurrent seizures without regaining consciousness.
Electroencephalography (EEG): Continuous or near-continuous epileptiform activity confirms NCSE or subtle SE.
Neuroimaging: Brain MRI or CT to identify underlying structural anomalies or acute causes (e.g., stroke, tumor).
Laboratory findings: Metabolic panel to identify abnormalities (e.g., glucose, electrolytes, lactate). Toxicology screen if substance-related causes are suspected.
Treatment
Airway, breathing, and circulation (ABCs): Ensure adequate oxygenation and establish IV access.
Monitor: Vital signs, oxygen saturation, and blood glucose levels.
First-line treatment (After 5-10 minutes): Intravenous lorazepam, diazepam or Midazolam is preferred.
Second-line treatment (After 10–20 minutes): Phenytoin, fosphenytoin, valproate, levetiracetam. Phenobarbital can be used for refractory cases.
Treatment options in refractory SE: Continuous IV anesthetic agents (e.g., propofol, midazolam, or thiopental). Close monitoring in the ICU with EEG.
Underlying cause management: Treating the infections with appropriate antibiotics or antivirals. Correction of metabolic or toxic abnormalities.
Prognosis
Outcomes depend on duration of SE, underlying etiology and response to treatment. Early intervention is critical for reducing mortality and long-term complications. Mortality rate can be as high as ~20% for adults. It is lower in children but increases with delayed treatment or systemic complications.
The risk for cognitive decline, worsening of pre-existing neurological conditions, recurrent seizures and development of epilepsy are higher in patients with status epilepticus.
Quality of Life
Emphasize the importance of medication adherence in individuals with epilepsy. Recognize early signs of prolonged seizures to seek immediate medical attention. Train families and caregivers to use emergency medications like rectal diazepam or intranasal midazolam. Cognitive or physical therapy for patients with neurological deficits post-SE.
Status epilepticus is a life-threatening condition requiring rapid intervention to prevent irreversible brain damage and systemic complications. A structured treatment approach, including benzodiazepines, antiepileptic drugs, and intensive care for refractory cases, ensures better outcomes. Early identification and management of underlying causes are essential for improving prognosis and preventing recurrence.
