Status Epilepticus

Definition 

Convulsive Status Epilepticus is defined as:

• Continuous generalized tonic–clonic seizure ≥5 minutes, OR
• Two or more seizures without complete recovery of consciousness between them

##Why 5 minutes?
Most self-terminating seizures stop within 1–2 minutes. Beyond 5 minutes, spontaneous termination is unlikely → treat as status epilepticus.

2️⃣ Time-Based Classification (ILAE Concept)

3️⃣ Pathophysiology 

Neurochemical Changes

• ↓ GABA-A receptor function (internalization)
• ↑ NMDA / glutamate activity
• Progressive benzodiazepine resistance

Systemic Effects

• Hypoxia, hypercapnia
• Lactic acidosis
• Hyperthermia
• Rhabdomyolysis
• Autonomic storm → arrhythmias, hypotension

## Key exam concept:

“The longer the seizure, the less responsive it becomes to benzodiazepines.”

4️⃣ Common Etiologies (Think: ACUTE + CHRONIC)

Acute Symptomatic Causes

• Stroke (ischemic / hemorrhagic)
• CNS infections (meningitis, encephalitis)
• Metabolic: hypoglycemia, hyponatremia, hypocalcemia
• Alcohol withdrawal
• Drug toxicity (INH, TCAs)

Chronic / Background Causes

• Known epilepsy with drug non-compliance
• Brain tumors
• Post-traumatic epilepsy

5️⃣ Clinical Features

• Generalized tonic–clonic movements
• Loss of consciousness
• Cyanosis, frothing
• Tongue bite, incontinence
• Persistent post-ictal coma (red flag)

6️⃣ Management: Time-Critical, Stepwise Approach

A. 0–5 Minutes: Immediate Stabilization

ABC first

• Airway protection
• High-flow oxygen
• IV access (2 large bore)
• Check RBS immediately
• If hypoglycemia → IV dextrose
• Send bloods: ABG, electrolytes, calcium, AED levels

B. 5–10 Minutes: First-Line Therapy (Benzodiazepine)

 Only ONE adequate dose(Repeated underdosing = treatment failure)

 C. 10–30 Minutes: Second-Line (Established SE)

Choose ONE loading agent:

Levetiracetam preferred due to:

• Minimal drug interactions
• Safe in hepatic disease
• No hypotension

D. >30 Minutes: Refractory Status Epilepticus (RSE)

 Failure of benzodiazepine + one second-line AED

Requires ICU + intubation

 Goal: EEG seizure suppression or burst suppression

7️⃣ Super-Refractory Status Epilepticus

• Seizures persist >24 hours despite anesthetic infusion

May require:

• Ketamine infusion
• Immunotherapy (if autoimmune encephalitis)
• Hypothermia
• Epilepsy surgery (rare)

8️⃣ Complications 

• Cerebral edema
• Hypoxic brain injury
• Aspiration pneumonia
• Rhabdomyolysis → AKI
• Metabolic acidosis
• Death

9️⃣ Prognosis

Depends on:

• Etiology (acute symptomatic worst)
• Duration before control
• Age & comorbidities

Mortality: 10–30%, higher in refractory SE.

1️⃣ Therapeutic Hypothermia in SRSE

Controlled reduction of core body temperature to 32–34 °C for seizure control and neuroprotection.

 Rationale (Why it may work)

Hypothermia:

• ↓ Cerebral metabolic rate (≈6–7% per °C)
• ↓ Glutamate release (excitotoxicity)
• ↑ GABAergic inhibition
• Stabilizes neuronal membranes
• ↓ Intracranial pressure

 Net effect: suppresses cortical hyperexcitability

 Protocol (Typical ICU Practice)

• Target temperature: 32–34 °C
• Duration: 24–48 hours
• Continuous EEG monitoring mandatory
• Controlled rewarming: 0.25–0.5 °C/hr

 Complications 

• Arrhythmias (especially bradycardia)
• Coagulopathy
• Infections (pneumonia, sepsis)
• Electrolyte shifts (↓ K⁺, Mg²⁺)
• Shivering → ↑ metabolic demand (needs sedation/paralysis)

 Exam pearl:Hypothermia is a rescue therapy with limited evidence, not standard of care.

2️⃣ Epilepsy Surgery in Status Epilepticus (Very Rare)

 What it means

Surgical resection or disconnection of an identified epileptogenic focus causing continuous seizures.

If SRSE is due to a focal structural lesion, removing the seizure focus may:

• Abort status
• Prevent further neuronal injury
• Be life-saving

 Indications (Strictly Selected Cases)

• Clearly localized seizure focus on:
• Continuous EEG
• MRI / PET / SPECT
• Causes include:
• Cortical dysplasia
• Tumor
• Post-traumatic scar
• Rasmussen encephalitis
• Failure of:
• Benzodiazepine
• Second-line AED
• Anesthetic coma

 Surgical Options

• Focal cortical resection
• Lobectomy
• Hemispherectomy (children, Rasmussen)
• Corpus callosotomy (palliative)