Status epilepticus is considered to have occurred when a generalised tonic-clonic seizure has lasted greater than 30 minutes.
Clinical and Historical assessment for cause
- Call for help – anaesthesia, paediatric neurologist
- Airway – open and secure airway, recovery position, high flow oxygen
- Breathing – ensure ventilation
- Circulation – ensure adequate circulation (20mL/kg crystalloid bolus), consider early antibiotic use to cover meningitis, routine bloods
— check conscious state, interictal periods, localising signs, pupillary response, glucose level, check for full fontanelle and neck stiffness (meningitis)
— terminate seizure:
-> rectal diazepam – 0.5mg/kg
-> buccal midazolam – 0.5mg/kg
-> IV lorazepam 0.1mg/kg
-> IV midazolam 0.15mg/kg
-> PR paraldehyde 0.4mg/kg (mixed 1:1 in olive oil)
-> phenytoin 18mg/kg over 30min
-> phenobarbitone 20mg/kg IV over 20 min
-> thiopentone 4mg/kg with RSI
-> volatile anaesthesia
- Exposure – rash to suggest infectious cause (esp. meningococcaemia), fever, poisoning (ecstasy, cocaine, saliciylates)
- consider empiric therapy of intracranial hypertension (0.25-0.5g/kg mannitol)
- look for complications: aspiration, arrhythmias, hypertension, APO, hyperthermia, DIC, rhabdomyolysis
- maintain normoglycaemia
- restrict fluids to 60% maintenance to avoid hyponatraemia
- normalised sodium to 135-145
- gastric decompression with NGT
- ventilate to CO2 – 35-40
- dexamethasone 0.2mg/kg bd for cerebral oedema from SOL
Diagnostic possibilities (COMATOSE)
- C – convulsion (primary or SOL)
- O – overdose
- M – meningitis
- A – adrenal failure
- T – trauma
- O – organ failure
- S – stroke
- E – end stage hypoxic ischaemic encephalopathy
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.