What are the guideline sources, guidelines and references for Status epilepticus ?
Guideline sources The following summarized guidelines for the evaluation and management of status epilepticus (SE) are prepared by our editorial team based on guidelines from the American Epilepsy Society (AES 2016), the The Scottish Intercollegiate Guidelines Network (SIGN 2015), the Neurocritical Care Society (NCS 2012), and the European Federation of Neurological Societies (EFNS 2010). 1 2 3 4 Guidelines 1. Screening and diagnosis Diagnostic criteria: define SE as 5 minutes of continuous clinical and/or electrographic seizure activity, or recurrent seizure activity without recovery between seizures. B 2. Classification and risk stratification Classification: Classify SE as either: convulsive SE: convulsions associated with rhythmic jerking of the extremities https://web.pathway.md/diseases/recYkcoQMnKV98lvi 1/6 6/24/23, 3:14 PM Status epilepticus Pathway non-convulsive SE: seizure activity seen on EEG without the clinical findings associated with convulsive SE. A Define refractory SE as SE not responding to the standard treatment regimens, such as an initial benzodiazepine followed by another antiepileptic drug. B 3. Diagnostic investigations Initial evaluation: As per SIGN 2015 guidelines: Obtain EEG to establish the diagnosis of SE and to monitor for treatment effect. Ensure that EEG is available as an emergency intervention in all patients with treated or suspected SE. B Do not deter or delay treatment in patients with SE because of nonavailability of EEG. B Obtain CBC, urea and electrolytes, LFTs, calcium, glucose, clotting, measurement of antiepileptic drug levels, and store the collected blood for later tests. Measure blood gases to assess the extent of acidosis. B As per NCS 2012 guidelines: Obtain the following in all patients with SE: monitoring of vital signs fingerstick glucose laboratory tests: blood glucose, CBC, basic metabolic panel, calcium (total and ionized), magnesium, antiepileptic drug levels head CT (appropriate for most cases) continuous EEG monitoring. E Consider obtaining the following tests in selected patients with SE, based on clinical presentation: additional laboratory tests: LFTs, serial troponins, type and hold, coagulation studies, arterial blood gas, antiepileptic drug levels, toxicology screen (urine and blood), and inborn errors of metabolism comprehensive toxicology panel including toxins frequently causing seizures (isoniazid, TCAs, theophylline, cocaine, sympathomimetics, alcohol, organophosphates, and cyclosporine) brain MRI lumbar puncture. E 4. Medical management General principles: As per SIGN 2015 guidelines, establish the etiology of SE. B Show 2 more https://web.pathway.md/diseases/recYkcoQMnKV98lvi 2/6 6/24/23, 3:14 PM Status epilepticus Pathway As per NCS 2012 guidelines: Identify and treat the etiology of SE as soon as possible. A Initiate treatment of SE, either convulsive A or non-convulsive, rapidly and continue sequentially until electrographic seizures are halted. B As per EFNS 2010 guidelines: Identify and treat the cause of SE urgently. E Use an in-house protocol for the general and specific pharmacological management of SE, to provide the highest quality of care. E Initial management: As per SIGN 2015 guidelines, initiate the following as soon as possible in patients with SE: securing airways oxygen supplementation assessment of cardiac and respiratory function securing IV access in large veins. B As per NCS 2012 guidelines: Initiate critical care treatment and monitoring simultaneously with emergent initial therapy and continued until further therapy is considered successful or futile. B Include the following measures in the critical care treatment of convulsive and non-convulsive SE completed prior or upon arrival to the ICU: noninvasive airway protection and gas exchange with head positioning intubation (if airway/gas exchange compromised or elevated intracranial pressure suspected) vital signs: (oxygen saturation, BP, HR) vasopressor support of BP if systolic BP is < 90 mmHg or mean arterial BP is < 70 mmHg fingerstick blood glucose peripheral IV access (for emergent initial antiepileptic drug therapy, fluid resuscitation, and nutrient resuscitation urgent SE control therapy with antiepileptic drugs neurologic examination triage laboratory testing panel refractory status epileptics treatment urinary catheter continuous EEG diagnostic testing, depending on clinical presentation (CT, MRI, lumbar puncture) intracranial pressure monitoring, depending on clinical presentation. As per EFNS 2010 guidelines, include the following in the general management approaches in generalized convulsive, complex partial, and subtle SE: assessment and control of the airways and ventilation https://web.pathway.md/diseases/recYkcoQMnKV98lvi 3/6 6/24/23, 3:14 PM Status epilepticus Pathway arterial blood gas monitoring to evaluate for metabolic acidosis and hypoxia requiring immediate treatment through airway management and supplemental oxygen ECG BP monitoring IV glucose and thiamine, as required emergency measurement of antiepileptic drug levels electrolytes and magnesium full hematological screen hepatic function tests renal function tests. E Antiepileptic drugs, emergent therapy: As per AES 2016 guidelines, administer benzodiazepines (specifically intramuscularly midazolam, IV lorazepam, or IV diazepam) as initial therapy in patients with SE. A Show 4 more As per SIGN 2015 guidelines: Administer any of the following options in patients with prolonged tonic-clonic seizures lasting 5 minutes: midazolam 10 mg buccally or intranasally lorazepam 4 mg IV if midazolam is unavailable diazepam 10 mg IV or rectally if midazolam and lorazepam are unavailable. B Administer a repeat dose of benzodiazepine in the hospital setting if there is no response after 10 minutes. B As per NCS 2012 guidelines, administer benzodiazepines as emergent initial therapy. A Administer lorazepam as the drug of choice for IV administration, and midazolam for intramuscularly administration. Consider administering rectal diazepam if IV access is not available and intramuscularly administration of midazolam is contraindicated. B As per EFNS 2010 guidelines, administer IV lorazepam 0.1 mg/kg as the preferred treatment in patients with generalized convulsive SE. A Consider initiating treatment at a lower dose of 4 mg, depending on the patient's general medical condition, and repeating this dose if SE is not terminated within 10 minutes. B Show 4 more Antiepileptic drugs, urgent therapy: As per AES 2016 guidelines, initiate the second therapy phase with fosphenytoin B , valproic acid B , or levetiracetam when the seizure duration reaches 20 minutes, concluded by the 40- minute mark when a response or lack of response to the second therapy is apparent. B Show 4 more As per SIGN 2015 guidelines, administer sodium valproate 20-30 mg/kg IV 40 mg/min or phenytoin 18 mg/kg IV 50 mg/min with ECG monitoring if seizures continue after 30 minutes. https://web.pathway.md/diseases/recYkcoQMnKV98lvi 4/6 6/24/23, 3:14 PM Status epilepticus Pathway Consider reducing the rate of phenytoin infusion if hypotension or arrhythmia occurs in older patients or if there is renal/hepatic impairment. B As per NCS 2012 guidelines, administer IV fosphenytoin/phenytoin, valproate sodium, or levetiracetam as anti-epileptic drugs for urgent control of seizures. B Management of refractory status epilepticus: As per AES 2016 guidelines, initiate the third therapy phase when the seizure duration reaches 40 minutes. Insufficient evidence to guide therapy in this phase. B As per SIGN 2015 guidelines, admit patients with seizures persisting > 30 minutes to an ICU and administer general anesthesia within 60 minutes, and refer for specialist advice. B As per NCS 2012 guidelines, treat refractory SE with continuous infusion anti-epileptic drugs, tailored to the patient's underlying condition. B Show 3 more As per EFNS 2010 guidelines, treat patients with generalized convulsive SE not responding to initial anticonvulsant substances in an ICU. E 5. Inpatient care Continuous EEG monitoring: As per SIGN 2015 guidelines: Obtain EEG to differentiate between continued seizures and drug-induced sedation if the patient remains unresponsive after initial treatment. B Obtain EEG to determine response to treatment in patients with seizures lasting > 30 minutes. B As per NCS 2012 guidelines: Obtain continuous EEG in most patients with SE. B Initiate continuous EEG within 1 hour of SE onset if ongoing seizures are suspected. Continue continuous EEG monitoring for 48 hours in comatose patients in order to evaluate for non-convulsive seizures. B Ensure that the healthcare professional reading EEG in the ICU setting has specialized training in continuous EEG interpretation, including the ability to analyze raw EEG as well as quantitative EEG tracings. B 6. Specific circumstances Pediatric patients: administer IV lorazepam or IV diazepam for stopping seizures lasting at least 5 minutes. A Show 6 more References https://web.pathway.md/diseases/recYkcoQMnKV98lvi 5/6 6/24/23, 3:14 PM Status epilepticus Pathway 1. Brophy GM, Bell R, Claassen J et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012 Aug;17 1 3 23. Open 2. Tracy Glauser, Shlomo Shinnar, David Gloss et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. Jan-Feb 2016;16 1 48 61. Open 3. SIGN. SIGN 143 Diagnosis and management of epilepsy in adults. SIGN, 2015. Open 4. H Meierkord, P Boon, B Engelsen et al. EFNS guideline on the management of status epilepticus in adults. Eur J Neurol. 2010 Mar;17 3 348 55. Open 5. Jaideep Kapur, Jordan Elm, James M Chamberlain et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019 Nov 28;381 22 2103 2113. Open 6. Arunodaya R Gujjar, Ramachandiran Nandhagopal, Poovathoor C Jacob et al. Intravenous levetiracetam vs phenytoin for status epilepticus and cluster seizures: A prospective, randomized study. Seizure. 2017 Jul;49 8 12. Open 7. Stephane Legriel, Virginie Lemiale, Maleka Schenck et al. Hypothermia for Neuroprotection in Convulsive Status Epilepticus. N Engl J Med. 2016 Dec 22;375 25 2457 2467. Open https://web.pathway.md/diseases/recYkcoQMnKV98lvi 6/6