Status Epilepticus (SE) is a critical neurological emergency that demands immediate medical attention. It is defined as a seizure lasting more than five minutes or a series of seizures where the patient fails to regain baseline consciousness between events. Without timely intervention, it can lead to irreversible brain damage, hypoxia, metabolic acidosis, and even death.
Causes and Risk Factors
The most common cause of status epilepticus is non-compliance with antiepileptic medications in patients with known epilepsy. Other causes include:
- Acute febrile illness or CNS infections
- Hypoglycemia or electrolyte imbalances
- Head trauma or stroke
- Drug withdrawal or overdose
- Metabolic disturbances
Pathophysiology and Complications
Prolonged seizures result in increased oxygen demand, excessive ATP consumption, and heat generation, leading to:
- Hyperthermia and rhabdomyolysis
- Metabolic acidosis due to lactic acid build-up
- Respiratory compromise, aspiration, or hypoxia
- Cardiac arrhythmias due to autonomic instability
Emergency Management: A Stepwise Approach
🔹 Step 1: Initial Stabilization (0–5 minutes)
- ABC Approach: Secure airway, ensure breathing, and maintain circulation
- Administer 100% oxygen
- Place a soft object between teeth to prevent tongue injury
- Establish two IV lines and draw blood for:
- Glucose, electrolytes, calcium, renal function tests
- Administer IV Dextrose even if hypoglycemia is not strongly suspected
🔹 Step 2: First-Line Therapy (5–10 minutes)
- Diazepam 5–10 mg IV at 1–2 mg/min
- May dilute in 10–20 mL NS
- Keep airway management tools ready due to risk of respiratory depression
🔹 Step 3: Second-Line Therapy (10–20 minutes)
- Phenytoin 20 mg/kg IV (in glucose-free line)
- Max infusion rate: 50 mg/min
- Effect onset: ~20 minutes
- Watch for hypotension or cardiac arrhythmias
🔹 Step 4: Third-Line Therapy (20–40 minutes)
- If seizures persist, give Phenobarbitone 20 mg/kg IV
- If needed, increment phenytoin dose by 5–10 mg/kg
- Ensure total infusion does not exceed safety limits
🔹 Step 5: Refractory Status Epilepticus (≥ 30–60 minutes)
- If no response, initiate general anesthesia with:
- Midazolam or Propofol
- Transfer to ICU for intubation and continuous ventilation
Monitoring and Supportive Measures
- Maintain continuous ECG and vital signs monitoring
- Prevent complications such as:
- Aspiration pneumonia
- Hyperthermia-induced injury
- Renal damage from rhabdomyolysis
- Address precipitating causes (e.g., infections, electrolyte imbalance)
Discharge and Long-Term Care
- Ensure medication compliance before discharge
- Educate patients and caregivers regarding seizure precautions
- Schedule neurologist follow-up for further workup and medication adjustment
Conclusion
Status epilepticus requires rapid recognition and structured management. From benzodiazepines to phenytoin, and eventually general anesthesia, each step must be executed efficiently to prevent irreversible outcomes. Timely interventions save lives—and preserve neurological function.
