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Medical management of status epilepticus: Emergency room to intensive care unit.
Seizure 2019S

Abstract

In convulsive status epilepticus (SE), achieving seizure control within the first 1-2 hours after onset is a significant determinant of outcome. Treatment is also more likely to work and be cost effective the earlier it is given. Initial first aid measures should be accompanied by establishing intravenous access if possible and administering thiamine and glucose if required. Calling for help will support efficient management, and also the potential for video-recording the events. This can be done as a best interests investigation to inform later management, provided adequate steps to protect data are taken. There is high quality evidence supporting the use of benzodiazepines for initial treatment. Midazolam (buccal, intranasal or intramuscular) has the most evidence where there is no intravenous access, with the practical advantages of administration outweighing the slightly slower onset of action. Either lorazepam or diazepam are suitable IV agents. Speed of administration and adequate initial dosing are probably more important than choice of drug. Although only phenytoin (and its prodrug fosphenytoin) and phenobarbitone are licensed for established SE, a now considerable body of evidence and international consensus supports the utility of both levetiracetam and valproate as options in established status. Both also have the advantage of being well tolerated as maintenance treatment, and possibly a lower risk of serious adverse events. Two adequately powered randomized open studies in children have recently reported, supporting the use of levetiracetam as an alterantive to phenytoin. The results of a large double blind study also including valproate are also imminent, and together likely to change practice in benzodiazepine-resistant SE.

Authors+Show Affiliations

Specialist Trainee Neurology, Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, UK.Professor of Epilepsy & Medical Education, Consultant Neurologist. Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, and Institute of Medical & Biomedical Education, St George's University of London, London, UK. Electronic address: hannahrc@sgul.ac.uk.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31722820

Citation

Crawshaw, Ania A., and Hannah R. Cock. "Medical Management of Status Epilepticus: Emergency Room to Intensive Care Unit." Seizure, 2019.
Crawshaw AA, Cock HR. Medical management of status epilepticus: Emergency room to intensive care unit. Seizure. 2019.
Crawshaw, A. A., & Cock, H. R. (2019). Medical management of status epilepticus: Emergency room to intensive care unit. Seizure, doi:10.1016/j.seizure.2019.10.006.
Crawshaw AA, Cock HR. Medical Management of Status Epilepticus: Emergency Room to Intensive Care Unit. Seizure. 2019 Oct 24; PubMed PMID: 31722820.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Medical management of status epilepticus: Emergency room to intensive care unit. AU - Crawshaw,Ania A, AU - Cock,Hannah R, Y1 - 2019/10/24/ PY - 2019/03/30/received PY - 2019/10/07/revised PY - 2019/10/08/accepted PY - 2019/11/15/entrez PY - 2019/11/15/pubmed PY - 2019/11/15/medline KW - Benzodiazepines KW - Levetiracetam KW - Phenytoin KW - Status epilepticus KW - Treatment KW - Valproate JF - Seizure JO - Seizure N2 - In convulsive status epilepticus (SE), achieving seizure control within the first 1-2 hours after onset is a significant determinant of outcome. Treatment is also more likely to work and be cost effective the earlier it is given. Initial first aid measures should be accompanied by establishing intravenous access if possible and administering thiamine and glucose if required. Calling for help will support efficient management, and also the potential for video-recording the events. This can be done as a best interests investigation to inform later management, provided adequate steps to protect data are taken. There is high quality evidence supporting the use of benzodiazepines for initial treatment. Midazolam (buccal, intranasal or intramuscular) has the most evidence where there is no intravenous access, with the practical advantages of administration outweighing the slightly slower onset of action. Either lorazepam or diazepam are suitable IV agents. Speed of administration and adequate initial dosing are probably more important than choice of drug. Although only phenytoin (and its prodrug fosphenytoin) and phenobarbitone are licensed for established SE, a now considerable body of evidence and international consensus supports the utility of both levetiracetam and valproate as options in established status. Both also have the advantage of being well tolerated as maintenance treatment, and possibly a lower risk of serious adverse events. Two adequately powered randomized open studies in children have recently reported, supporting the use of levetiracetam as an alterantive to phenytoin. The results of a large double blind study also including valproate are also imminent, and together likely to change practice in benzodiazepine-resistant SE. SN - 1532-2688 UR - https://www.unboundmedicine.com/medline/citation/31722820/Medical_management_of_status_epilepticus:_Emergency_room_to_intensive_care_unit L2 - https://linkinghub.elsevier.com/retrieve/pii/S1059-1311(19)30204-3 DB - PRIME DP - Unbound Medicine ER -