eMedicine Specialties > Emergency Medicine > Neurology
Status Epilepticus: Follow-up
Updated: Aug 24, 2009
Follow-up
Further Inpatient Care
- Emergency physicians must stop the seizures, stabilize the patient's medical condition, look for the etiology of the seizures, coordinate care with appropriate physicians, and make disposition to the appropriate service and medical unit.
- Care of the patient may involve interaction with a number of specialty or primary care physicians, including neurologists, neurosurgeons, internists, pediatricians, family practitioners, or intensivists.
- Continuous EEG monitoring may be desirable if a question exists about termination of status epilepticus or the presence of subtle status epilepticus.
- Coordinate treatment of associated injuries or complications with the inpatient service.
Further Outpatient Care
- Most patients with status epilepticus are admitted to the hospital not only for seizure control but also for treatment of other medical conditions that may be causing the seizures.
- Patients with a flurry of seizures that are easily controlled might conceivably be discharged after several hours of observation.
- The presence and capability of caretakers, proximity to the hospital, and comorbid medical conditions all factor into this decision.
Transfer
- Failure to terminate the seizures or need for critical care may be reasons for transfer. Transfer to a facility with expertise in this area may be desirable after the patient's condition has been stabilized.
Deterrence/Prevention
- Encourage anticonvulsant therapy compliance and alcohol abstinence.
- Emphasize the importance of regular medical attention for medication adjustment.
- Arrange for follow-up visits to adjust medications and for further medical workup and care.
Complications
- Complications of status epilepticus are many. As discussed in Pathophysiology section, current thought is that the abnormal electrical discharges themselves may cause neuronal damage.
- Systemic complications
- Hyperthermia
- Acidosis
- Hypotension
- Respiratory failure
- Rhabdomyolysis
- Aspiration
Prognosis
- Prognosis is related most strongly to the underlying process causing status epilepticus. For example, if meningitis is the etiology, the course of that disease dictates outcome.
- Patients with status epilepticus from anticonvulsant irregularity or those with alcohol-related seizures generally have a favorable prognosis if treatment is commenced rapidly and complications are prevented.
Patient Education
- Reinforcement of compliance with prescribed medications at routine clinical encounters may be helpful.
- For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education article Seizures Emergencies.
Miscellaneous
Medicolegal Pitfalls
- Failure to diagnose and treat the underlying cause of the seizures is a major pitfall because status epilepticus is often secondary to another pathologic process.
- Failure to recognize associated injuries or complications, such as aspiration pneumonia, is a potential problem.
- Failure to identify subtle or nonconvulsive status epilepticus in the patient with a coma or altered mental status but without convulsive motor seizures is an increasingly recognized pitfall.
- Seizures in association with hypertension in late pregnancy (or postpartum) may represent eclampsia.
Special Concerns
- In a small case series, several patients post-cardiac arrest treated with therapeutic hypothermia who developed postanoxic status epilepticus had a favorable outcome with aggressive treatment of the status epilepticus.7
- A paradox currently exists in that the criterion standard for diagnosing status epilepticus, the EEG, rarely is available in the acute-care setting.
- The work of Treiman et al suggests that electrical status epilepticus often persists when clinical seizure activity has ceased.8
- High clinical suspicion for continued unresponsiveness from this subtle status epilepticus is necessary along with timely consultations and occasional insistence on obtaining EEG.
More on Status Epilepticus |
| Overview: Status Epilepticus |
| Differential Diagnoses & Workup: Status Epilepticus |
| Treatment & Medication: Status Epilepticus |
 Follow-up: Status Epilepticus |
| References |
| « Previous Page |
References
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DeLorenzo RJ, Hauser WA, Towne AR, Boggs JG, Pellock JM, Penberthy L, et al. A prospective, population-based epidemiologic study of status epilepticus in Richmond, Virginia. Neurology. Apr 1996;46(4):1029-35. [Medline].
Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med. Apr 2 1998;338(14):970-6. [Medline].
Leis AA, Ross MA, Summers AK. Psychogenic seizures: ictal characteristics and diagnostic pitfalls. Neurology. Jan 1992;42(1):95-9. [Medline].
Jagoda A, Richey-Klein V, Riggio S. Psychogenic status epilepticus. J Emerg Med. Jan-Feb 1995;13(1):31-5. [Medline].
[Guideline] ACEP Clinical Policies Committee; Clinical Policies Subcommittee on Seizures. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med. May 2004;43(5):605-25. [Medline].
Rossetti AO, Oddo M, Liaudet L, Kaplan PW. Predictors of awakening from postanoxic status epilepticus after therapeutic hypothermia. Neurology. Feb 24 2009;72(8):744-9. [Medline].
Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, et al. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group. N Engl J Med. Sep 17 1998;339(12):792-8. [Medline].
Aggarwal P, Wali JP. Lidocaine in refractory status epilepticus: a forgotten drug in the emergency department. Am J Emerg Med. May 1993;11(3):243-4. [Medline].
[Guideline] Epilepsy Foundation of America's Working Group. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. Aug 18 1993;270(7):854-9. [Medline].
Fountain NB, Lothman EW. Pathophysiology of status epilepticus. J Clin Neurophysiol. Jul 1995;12(4):326-42. [Medline].
Huff JS. Seizures and status epilepticus in adults: Part II. Emerg Med Rep. 2007;28(24):281-88.
Kumar A, Bleck TP. Intravenous midazolam for the treatment of refractory status epilepticus. Crit Care Med. Apr 1992;20(4):483-8. [Medline].
Limdi NA, Shimpi AV, Faught E, Gomez CR, Burneo JG. Efficacy of rapid IV administration of valproic acid for status epilepticus. Neurology. Jan 25 2005;64(2):353-5. [Medline].
Lowenstein DH, Alldredge BK. Status epilepticus at an urban public hospital in the 1980s. Neurology. Mar 1993;43(3 Pt 1):483-8. [Medline].
Prasad A, Worrall BB, Bertram EH, Bleck TP. Propofol and midazolam in the treatment of refractory status epilepticus. Epilepsia. Mar 2001;42(3):380-6. [Medline].
Privitera MD, Strawsburg RH. Electroencephalographic monitoring in the emergency department. Emerg Med Clin North Am. Nov 1994;12(4):1089-100. [Medline].
Wheless JW, Vazquez BR, Kanner AM, Ramsay RE, Morton L, Pellock JM. Rapid infusion with valproate sodium is well tolerated in patients with epilepsy. Neurology. Oct 26 2004;63(8):1507-8. [Medline].
Further Reading
Keywords
status epilepticus, generalized convulsive status epilepticus, GCSE, seizure, subtle status epilepticus, nonconvulsive status epilepticus, epilepsy, seizure disorder, tonic-clonic activity, persistent tonic seizure, idiopathic seizure disorder, stroke, hypoxic injury, tumor, subarachnoid hemorrhage, trauma, toxicologic effects, electrolyte abnormality, hyponatremia, hypernatremia, hypercalcemia, hepatic encephalopathy, meningitis, brain abscess, encephalitis, metabolic acidosis, isoniazid toxicity, anticonvulsant irregularity
