The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care

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This is an extract from the guidance. The complete guidance is available at guidance.nice.org.uk/cg137

Appendix F: Protocols for treating convulsive status epilepticus in adults and children (adults published in 2004 and children published in 2011)

Treating convulsive status epilepticus in adults (published in 2004)
Guidelines for treating convulsive status epilepticus in children (published in 2011)
Non-convulsive status epilepticus in adults and children (2004 guideline)

Treating convulsive status epilepticus in adults (published in 2004)

General measures
1st stage (0−10 minutes) Secure airway and resuscitate Administer oxygen Assess cardiorespiratory function Establish intravenous access	Early status
2nd stage (0−30 minutes) Institute regular monitoring Consider the possibility of non-epileptic status Emergency AED therapy Emergency investigations Administer glucose (50 ml of 50% solution) and/or intravenous thiamine (250 mg) as high potency intravenous Pabrinex if any suggestion of alcohol abuse or impaired nutrition Treat acidosis if severe
3rd stage (0−60 minutes) Establish aetiology Alert anaesthetist and ITU Identify and treat medical complications Pressor therapy when appropriate	Established status
4th stage (30−90 minutes) Transfer to intensive care Establish intensive care and EEG monitoring Initiate intracranial pressure monitoring where appropriate Initiate long-term, maintenance AED therapy	Refractory status
Emergency investigations Blood should be taken for blood gases, glucose, renal and liver function, calcium and magnesium, full blood count (including platelets), blood clotting, AED drug levels; 5 ml of serum and 50 ml of urine samples should be saved for future analysis, including toxicology, especially if the cause of the convulsive status epilepticus is uncertain. Chest radiograph to evaluate possibility of aspiration. Other investigations depend on the clinical circumstances and may include brain imaging, lumbar puncture.
Monitoring Regular neurological observations and measurements of pulse, blood pressure, temperature. ECG, biochemistry, blood gases, clotting, blood count, drug levels. Patients require the full range of ITU facilities and care should be shared between anaesthetist and neurologist. EEG monitoring is necessary for refractory status. Consider the possibility of non-epileptic status. In refractory convulsive status epilepticus, the primary end-point is suppression of epileptic activity on the EEG, with a secondary end-point of burst-suppression pattern (that is, short intervals of up to 1 second between bursts of background rhythm).

Emergency AED therapy for convulsive status epilepticus (published in 2004)

Premonitory stage (pre-hospital)	Diazepam 10−20 mg given rectally, repeated once 15 minutes later if status continues to threaten, or midazolam 10 mg given buccally. If seizures continue, treat as below.
Early status	Lorazepam (intravenous) 0.1 mg/kg (usually a 4 mg bolus, repeated once after 10−20 minutes; rate not critical). Give usual AED medication if already on treatment. For sustained control or if seizures continue, treat as below.
Established status	Phenytoin infusion at a dose of 15–18 mg/kg at a rate of 50 mg/minute or fosphenytoin infusion at a dose of 15−20 mg phenytoin equivalents (PE)/kg at a rate of 50–100 mg PE/minute and/or phenobarbital bolus of 10–15 mg/kg at a rate of 100 mg/minute.
Refractory status ^a	General anaesthesia, with one of: propofol (1–2 mg/kg bolus, then 2–10 mg/kg/hour) titrated to effect midazolam (0.1–0.2 mg/kg bolus, then 0.05–0.5 mg/kg/hour) titrated to effect thiopental sodium (3–5 mg/kg bolus, then 3–5 mg/kg/hour) titrated to effect; after 2–3 days infusion rate needs reduction as fat stores are saturated anaesthetic continued for 12−24 hours after the last clinical or electrographic seizure, then dose tapered.
^a In the above scheme, the refractory stage (general anaesthesia) is reached 60/90 minutes after the initial therapy.

This scheme is suitable for usual clinical hospital settings. In some situations, general anaesthesia should be initiated earlier and, occasionally, should be delayed.

Experience with long-term administration (hours or days) of the newer anaesthetic drugs is very limited. The modern anaesthetics have, however, important pharmacokinetic advantages over the more traditional barbiturates.

AED therapy must be given in parallel with emergency treatment. The choice of drug depends on previous therapy, the type of epilepsy, and the clinical setting. Any pre-existing AED therapy should be continued at full dose, and any recent reductions reversed.

If phenytoin or phenobarbital has been used in emergency treatment, maintenance doses can be continued orally or intravenously guided by serum level monitoring. Other maintenance AEDs can be started also, with oral loading doses. Care needs to be taken with nasogastric feeds, which can interfere with the absorption of some AEDs. Once the patient has been free of seizures for 12−24 hours and provided that there are adequate plasma levels of concomitant AEDs, then the anaesthetic should be slowly tapered.

Guidelines for treating convulsive status epilepticus in children (published in 2011)

The original guidelines for the treatment of convulsive status epilepticus (CSE) were published in 2000. They were subsequently adopted by the Advanced Life Support Group (ALSG) and taught in their courses across the UK and Europe. They represent the basis for much of the management of CSE by junior doctors although they are not intended to cover all situations. They are hospital guidelines and take no account of pre-hospital treatment. They do not include infants, those born very prematurely and/or less than 28 days of age. Also, they do not cover children who have frequent episodes of CSE for whom an individually tailored guideline is the best option as their seizures may respond better to specific treatments than others.

Generalised convulsive (tonic–clonic) status epilepticus is defined as a generalised convulsion lasting 30 minutes or longer, or repeated tonic–clonic convulsions occurring over a 30 minutes period without recovery of consciousness between each convulsion. However, the guideline stated that 'for practical purposes, the approach to the child who presents with a tonic–clonic convulsion lasting more than 5 minutes should be the same as the child who is in "established" status – to stop the seizure and to prevent the development of status epilepticus'. The consensus guideline can be seen in the table below.

Treating convulsive status epilepticus

Time 0 mins (1^st step)	Seizure starts Check ABC, high flow O₂ if available Check blood glucose	Confirm clinically that it is an epileptic seizure
5 mins (2^nd step)	Midazolam 0.5 mg/kg buccally or Lorazepam 0.1 mg/kg if intravenous access established	Midazolam may be given by parents, carers or ambulance crew in non-hospital setting
15 mins (3^rd step)	Lorazepam 0.1 mg/kg intravenously	This step should be in hospital Call for senior help Start to prepare phenytoin for 4^th step Re-confirm it is an epileptic seizure
25 mins (4^th step)	Phenytoin 20 mg/kg by intravenous infusion over 20 mins or (if on regular phenytoin) Phenobarbital 20 mg/kg intravenously over 5 mins	Paraldehyde 0.8 ml/kg of mixture may be given after start of phenytoin infusion as directed by senior staff Inform intensive care unit and/or senior anaesthetist
45 mins (5^th step)	Rapid sequence induction of anaesthesia using thiopental sodium 4 mg/kg intravenously	Transfer to paediatric intensive care unit

When the protocol is initiated it is important to consider what pre-hospital treatment has been received and to modify the protocol accordingly.

Non-convulsive status epilepticus in adults and children (2004 guideline)

Suggested by the 2004 Guideline Development Group.

This is less common than tonic–clonic status epilepticus. Treatment for non-convulsive status epilepticus is less urgent than for convulsive status epilepticus. Treatment should be considered as follows:

maintenance or reinstatement of usual oral AED therapy
use of intravenous benzodiazepines under EEG control, particularly if the diagnosis is not established
referral for specialist advice and/or EEG monitoring.