The goal of treatment of convulsive status epilepticus and epilepsia partialis continua is seizure control within 30 min of presentation ( Fig..224:1). Morbidity is due hypoxemia, hyperthermia, circulatory collapse, and eventual neuronal injury.
A brief history and physical examination should be directed toward discovery of the cause of the seizures and to any injury that may have resulted. Any of the causes of seizures (see T.a.b..l.e 22.4.-.2.) may result in status epilepticus; in many patients, no specific etiology is found.
A large-bore IV line should be established and a bedside glucose determination made. Use of an IV fluid without glucose will facilitate administration of anticonvulsant drugs (glucose is not compatible with phenytoin). The patient should be placed on oxygen, a cardiac monitor, and pulse oximeter.
Despite periods of apnea and cyanosis, which can occur during seizure activity, most patients can be maintained on nasal cannula or oxygen mask with a nasopharyngeal device if the gag reflex and airway are intact. Endotracheal intubation should be performed if there is any concern about the adequacy of ventilation or safety of the airway. Many prefer orotracheal intubation because the patient is likely to undergo diagnostic imaging and may require procedures. If a paralytic agent is used to assist with intubation, a short-acting agent, such as vecuronium, should be used as the physician will be unable to monitor ongoing seizure activity during the period of paralysis.
Initial laboratory evaluation should include blood glucose, metabolic panel including calcium and magnesium, and, if appropriate, a pregnancy test, a toxicology screen, and anticonvulsant levels.
Thiamine (100 mg) and glucose (25 to 50 g) should be given IV if hypoglycemia is suspected or confirmed. There is no benefit to giving additional glucose to normoglycemic patients. Rectal temperature should be monitored, and hyperthermia should be treated with passive cooling. A Foley catheter should be placed to monitor urine output and the nasogastric tube to minimize aspiration.
If ingestion is suspected as the cause of seizures, GI decontamination should ensue. Emergency lumbar puncture should not be attempted during status epilepticus. If bacterial meningitis is suspected, empiric antibiotic therapy should be started. Status epilepticus can induce a brief peripheral leukocytosis as well as a mild CSF pleocytosis. Radiographic studies (such as a CT scan) will usually need to be delayed until the seizures are controlled.
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