Epilepsia, 17:73-76, 1976. Raven Press, New York.

The Treatment and Management of Emergency Status Epilepticus M. Sahal Khalid and H. Schulz Institute of Psychiatry and Neurology, Charitb Hospital, Schumann Str. 5, Berlin, West Germany (Received December 15,1975) usually either astrocytoma or multiform gliablastoma. The lesion is usually unilateral When we discuss status epilepticus as an frontal or frontal temporal. Bilateral frontal emergency among adults, we usually mean the lesions usually cause frontal akinesia (Janz, 1961; Ketz, 1967). Traumatic brain damage can grand ma1 status, although a Jacksonian status! at an advanced stage could also be considered also cause status epilepticus. In addition, any of the following can within the same category and is treated with almost the same routine (Mumenthaler, 1970). provoke status epilepticus in a patient with a A grand ma1 status epilepticus is present history of epilepsy or with a predisposition to when the fits follow each other so closely that it. (1) Insufficient treatment with anticonconsciousness is not recovered in between. This is usually the case when the interval between vulsants (2) Sudden withdrawal of anticonvulsant fits is approximately 5 to 1 5 min. If the interval is more than 1 hour, we speak of a series of drugs,2 due mostly to ignorance (the patient frequent fits (Janz and Kautz, 1963). In the believes he is completely cured because the United States, status is assumed if there are convulsions have been controlled by drugs, and three fits in 30 min, or a general or focal seizure so he just stops taking the medicine) (3) Withdrawal of anticonvulsive medication lasting more than 10 min. Some authors regard any increase of fits in a patient as potential in the course of preparing the patient for status (Slater and Sargent). Others note that an surgery or for an EEG isolated grand ma1 status is always sympto(4) Intercurrent infections, which cause inmatic; either it occurs during the course of an ternal withdrawal of the drug (Kaeser, 1967) acute illness, such as encephalitis, or it is due to (5) Cerebral vascular processes a tumor, in which case the status epilepticus is (6) Cerebral anoxia, due, for example, to then of a recurrent nature. Such tumors are cardial failure (7) Alcohol, lack of sleep, or pregnancy. INTRODUCTION

Key words: Emergency status epilepficus Anticonvulsive drugs Some authors identify the Jacksonian status epilepticus with the koshewinikoff’s “epilepsia partialis continua.” Others reject this substitution maintaining that the latter is primarily of subcortical origin. Clinically, however, they often d o resemble each other; o n the other hand, Jacksonian status a t an advanced stage causes the convulsive involvementof both sides o f t h e body and the loss of consciousness. At this stage it resembles grand ma1 status (Mumenthaler, 1969).

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Status epilepticus, which has a frequency of about 6% among epileptic patients, still has quite a significant mortality rate of 8 to 33% (Ketz, 1967). Fatality among patients with status epilepticus usually results from aspiraSudden withdrawal of barbiturates. and some tranquilizers as well, could cause an epileptiform fit in healthy subjects or, rather, in persons who had n o previous history of epilepsy.

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tion, cerebral edema, circulatory failure, or hyperthermia. The earlier treatment is begun, the better the prognosis. A relatively good prognosis lies in starting medication within the first hour (2 hr at most) (Schulz, 1970). This also means that treatment of status epilepticus has two objectives: stopping the convulsions and controlling the secondary consequences, such as cerebral edema, metabolic and respiratory acidosis, and the circulatory condition. Since the convulsions are clinically outstanding, the management of the secondary consequences is occasionally neglected.

TREATMENT OF ADULTS

(1) Diazepam: administered slowly i.v. (10 mg/5 min) until the convulsions are controlled (maximum 60-80 mg) (Schulz, 1970). The duration of the effect by i.v. application is 30-60 min; therefore, after controlling the convulsions, we give 10 mg diazepam i.m., the effect of which lasts for 1-3 hr. In more difficult cases we administer diazepam in the form of i.v. infusion over 3-5 hr, whereas the full dose, including the preceding injections, would not exceed 80-100 mg.3 Others give up t o 200 mg diazepam in an adult over a 24-hr period (Sargent and Slater). The rate of the infusion is adjusted to control the seizure activity. If an EEG is available, it can be used as a guide for the rate of infusion. (2) In some cases we provide, simultaneously with the diazepam infusion, an i.v. drip of procaine (Novocain@) in 1%solution (dose up to 10 mg/kg body weight/hr) (Ketz, 1967) at a speed of 40-60 drops/min until the blood pressure is back to normal level and then readjust t o 30 drops/min. Further controls of blood pressure are required. Lidocaine, 1 0 mg/kg body weight/hr can also be used (Eriksson and Gordh, 1970). (3) If within 20 min no effect is noticed, the patient is given hexobarbital i.v. slowly until the convulsions stop (maximal dose 0.5). If it is possible to perform intubation narcosis and relaxation under the guidance of an anesthetist, and with all precaution, we can give a higher dose of hexobarbital. With the patient under anesthesia we would clinically observe the duration of the convulsions through the enlarged pupils. (4) Usually the steps taken by now would suffice. In case of failure, however, we could use chloral hydrate in rectal infusion (dose 3.4.-4.0.), which is to be stopped as soon as control of convulsions is achieved. Then a classic anticonvulsant, e.g., phenobarbital, would be given i.m. According t o Schulz this is quite an effective combination. Phenobarbital sodium is given in an intramuscular injection of 6 mg/kg body weight. (5) Another alternative, as a rectal enema, is paraldehyde (7 to 14 cc, maximum 21 cc;

For quite a long time, barbiturates were the drugs of choice in treating status epilepticus. Although they offer certain disadvantages, such as depressing the respiratory centers and affecting the circulatory condition of the patient unfavorably, they are still popular in some clinics. This popularity, however, is losing ground since Gastaut introduced the benzodiazepine derivative diazepam (Valium@) in treating status epilepticus (Gastaut et al., 1966). Diazepam is a relatively safe drug, which might depress the respiratory centers or cardial activity only in huge doses (Kelly, 1973). It has proved to be effective in controlling status. Its main drawback is that it is relatively short-acting, a shortcoming which could easily be compensated through the mode and technique of application, as we shall describe further on. Another drug which is becoming prominent in this field is chlormethiazole, an aneurin derivative with the commercial names Distraneurin@ and Heminewins. Unfortunately it is not yet available in the United States. Chlormethiazole was at first used in controlling the motor excitement within delirium tremens; it is still the drug of choice for that problem. Recently doctors in West Germany began treating status epilepticus with it. We personally observed 2 cases resistant t o the diazepam routine which then responded t o the i.v. infusion of 0.8% 500ml Distraneurin@ We have experienced good results with solution, i.e., 15-20 g. We will, however, restrict promethazine (PhenerganB), 50 mg., given i.m. a t this stage. ourselves to drugs currently available here.

TREATMENT OF EMERGENCY STATUS EPILEPTICUS

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Dunlope and Davidson, 1950), which we would (Gibbels, 1969) and, with it, nitrazepam also stop as soon as control is achieved. We (Mogadona) at a dose of 2.5 mg t.d.s. (Ketz, proceed then with classic anticonvulsant drugs, 1967). (3) Good results are obtained with the parenterally at first with intervals of 3, 6, or 8, hr according t o the individual condition and the administration of sodium diphenylhydantoin appropriate drug, whether a barbiturate or a (phenytoin, epanutin) in children up to 1 1 / 2 diphenylhydantoin (epanutin, phenytoin). The years old, less than 100 mg i.m. or i.v. slowly latter has the advantage of not altering the state (ca. 50 mg/min). Above that age, a child can of consciousness and not depressing the safely receive a dose of 120-250 mg (Manisrespiratory centers. It could, however, cause sadjian, 1961). Since the effect starts after anuria to patients with renal disease. Slater and approximately 20 min, it is usually combined Roth (1972) administer paraldehyde as a deep with the diazepam routine. (4) Barbiturates, as already mentioned, are intramuscular injection of 1 0 to 1 2 ml followed by 5 ml every 30 min until the fits cease. In not considered by many as a drug of first fact, they regard it as the most effective drug in choice. Doose (1967), however suggests the use status; they would apply it even intravenously, of a preparation which contains a quick- and a when it seems t o be unavoidable. It would then slow-acting barbiturate such as Sommifen@ be given as 10% solution in 500 ml water by (barbital plus aprobarbital). It would then be drip. Note: when paraldehyde is to be given, applied with glucose i.v. For infants, the dosage the solution should be checked for stability and is 60-150 mg; for small children, up to 200 mg; for school children, up to 400 mg. The commust be given in a glass syringe. bination of i.v. diazepam and i.m. phenobarbital is quite commonly used (Schulz, TREATMENT OF CHILDREN 1970). (5) Some conservative clinics still prefer (1) Again, because of its therapeutic chloral hydrate rectal. infusion in children as spectrum, diazepam is the drug of choice in well. The dose is 0.1-0.8 g in infants (average treating status epilepticus in children (Matthes, 0.4 g), 1.0-1.5 g in small children, and 2.0 g in 1966). Infants and small children are given school children. 10-20 mg i.m. and/or 2-10 mg i.v. according t o age and clinical estimation (Lombroso, 1966; Kaeser, 1967), with the average dose 4 mg i.v. PATIENT MANAGEMENT DURING TRANS slowly (Matthes, 1966). Children of about 6 PORT IN THE CLINIC years old can be given up t o 15-20 mg i.v. at the usual slow speed of 10 mg/5 min (Matthes, (1) Diazepam as described previously. 1966). Sargent arid Slater advise that diazepam (2) Phenobarbital, 200 mg i.m. (or accordbe given to children in doses of either 0.25 mg ing to age or body weight). t o 0.5 mg/kg body weight or 1to 2 mg per year It must be pointed out however, that the of life. As there is usually in such cases a recidivistic tendency, a combination with i.m. treatment of status epilepticus is not to be sought in a scheme or to be restricted by it. It is barbiturate or hydantoin is quite useful. (2) In cases of propulsive petit ma14 status to be adjusted according t o the age, the general (Janz, 1967; Penin, 1967), it is necessary to conditions, the severity of the convulsions, the give a large dose of ACTH, 40-160 I.U./per day main cause of the status, and the secondary complications. Janz and Kautz summed up the reasons for failure to control status epilepticus 4Janz and Matthes (1955) introduced this (Schultz, 1970): (1) The initial dose was too term and it is now very popular in continental small. (2) The continuation of the treatment Europe. They claim that the other names for was delayed or given in scattered doses. (3) A this syndrome are either nonspecific, as in parenteral coverage with antiepilepticus until “infantile spasms,” or unscientific and descriptively inaccurate, as in “salam jerks.” They the patient could take oral treatment was not argue further that t h e term hypsarrhythmia is done. pure EEG terminology. To conclude this section, the different drugs

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Hyperthermia, which is more common among small children (Doose, 1967), is also of real danger (Dunlop and Davidson, 1950). It is (1) Diazepam applied i.v., as infusion, and usually t o be treated with strong measures. i.m. Tepid sponging helps in temperatures of about (2) Paraldehyde applied as rectal infusion or 10l0F; in higher temperatures of around i.m. or even i.v. 106°F. all clothes should be removed from the (3) Chlormethiazole applied as i.v. infusion patient, his skin rubbed, and ice then applied to (4) Barbiturates (sodium amylobarbital or the surface of the body (Dunlop and Davidson, phenobarbital sodium) applied i.v. and i.m. 1950). Schultz suggests also giving aminophena(5) Chloral hydrate (among children it is, zone (0.1 for infants, 0.2 for small children). like diazepam, first choice) applied as rectal Antibiotics should be given as prophylaxis. infusion Contraindicated are morphine, nikethamide (6) Diphenylhydantoin (phenytoin) applied (CoramineB), and the phenothiazines,’ except i.v. and i.m. pro me th az in e. (7) General anesthetics

which can be used are listed according to priority .

REFERENCES GENERAL MEASURES (SPECIFICALLY IN RELATION TO THE MAIN COMPLICATIONS) Notify the local intensive care unit, provided there is one, that a case of status epilepticus has occurred. Respiratory Condition Severe status as well as some of the anticonvulsive drugs used could cause sudden respiratory failure (Schulz, 1970). As soon as possible, the patient should be put in the well-known stable lateral position with the jaw forward and the neck extended. This secures a better airpath and reduces the danger of aspiration. For the sawe reasons reported suction should be performed. Some clinics give one amp. of atropine sulfuricum S.C. as well. The blood must be sufficiently oxygenated. Accordingly, the patient may receive pure O2 for 5 min, repeated 3 to 5 times/hr. In cases of prolonged deep coma we apply prolonged intubation; sometimes tracheostomy should seriously be considered. Cerebral Edema Cerebral edema can be managed with i.v. infusion of low molecular dextran, such as RheumakrodexB, and hypertonic solutions and perhaps a thiazide derivative. The combined metabolic and respiratory acidosis is to be treated with an appropriate i.v. infusion of sodium bicarbonate.

Bamberger, Ph and Matthes A. Z Kinderheilkd 95:155-163, 1966. Doose, H. Monatsschr Kinderheilkd 115:537538,1967. Dunlope and Davidson. Textbook of Therapy in Medicine. 1950. Eriksson and Gordh. Atlas der Lokalanaesthesie. Stuttgart, 1970. Gastaut, H et al. Epilepsia 7:139, 1966. Janz, D and Kautz C. Dtsch Med Wochenschr 88: 2189, 1963. Janz, D and Matthes A. Bibl. Pediat. Fasc. 60. Karger, Basel, New York, 1955. Kaeser, HE. Praxis 56:22, 750, 1967. Ke1ly.JPsychiatry (Lond), 1973. Ketz, E. Ther Gwg 106:741, 1967. Kulz, J. Medicamentum 101:6-11, 1969. Lombroso, CT. Neurology (Minneap.) 16, 1966. Manissadjian et al. NeuroPsiquiatry 19:226, 1961. Miiller, HR e t al. Schweiz Med Wochenschr 96:121, 1966. Mumenthaler.Neurology Lehrbuch. 1970. Okasha, A. Textbook of Psychiatry. Cairo, 1967. Parsonage and Norris..Br Med J 3:85, 1967. Sargent and Slater. Physical Therapy in Psychiatry. Slater and Roth. Meyer-Gross Textbook of Clinical Psychiatry. 1972 edition. Vogel, P. Psychiatr Neurol Med Psycho1 19:461 1967.

’Interestingly enough, the Leningrad School

of the Soviet Union claims success in treating

status epilepticus with huge doses of chlorpromazine. Under certain circumstances, some authors (Okasha, 1967) applied E.C.T. They maintain that one single E.C.T. would sometimes terminate status epilepticus.

The treatment and management of emergency status epilepticus.

Epilepsia, 17:73-76, 1976. Raven Press, New York. The Treatment and Management of Emergency Status Epilepticus M. Sahal Khalid and H. Schulz Institut...
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