eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Critical Care

Status Epilepticus: Follow-up

Author: Marcio Sotero de Menezes, MD, Associate Professor, Department of Neurology, Division of Pediatric Neurology, Children's Hospital of Seattle, University of Washington
Coauthor(s): Ednea Simon, MD, Acting Assistant Professor, Department of Neurology, University of Washington
Contributor Information and Disclosures

Updated: Jul 13, 2009

Follow-up

Further Inpatient Care

  • Treat patients with status epilepticus (SE) who have suspected herpes encephalitis with acyclovir until the diagnosis can be confirmed. Suspect herpes virus encephalitis in all patients with fever, mental status changes, and de novo onset of partial seizures, with or without secondary generalization.
  • Treatment of catscratch disease is not universally efficacious; rifampin, ciprofloxacin, and trimethoprim-sulfamethoxazole have been successfully used.
  • Electrolyte disturbances may cause or perpetuate seizures; hypocalcemia and hyponatremia are the most common. Efforts to correct hyponatremia should be performed carefully because quick shifts in serum osmolality may cause irreversible brain damage from central pontine myelinolysis. Correcting hypocalcemia with intravenous (IV) calcium gluconate should be performed under ECG monitoring because of the possibility of cardiac arrhythmias.

Further Outpatient Care

  • Long-term antiepileptic therapy after generalized tonic-clonic status epilepticus (GTCSE) includes the following:
    • Although a complete guide for outpatient management of epilepsy is beyond the scope of this article, the Epilepsy Foundation Working Group on status epilepticus recommends starting some patients, including those with a history of epilepsy or brain lesion, on long-term antiepileptic therapy after a status epilepticus episode.
    • No long-term therapy is indicated for status epilepticus caused by transient problems (eg, metabolic disturbances [hyponatremia], intoxications).
    • No consensus regarding the need for treatment after an instance of febrile status epilepticus or when a first unprovoked seizure is a status epilepticus episode has been reached.
    • Although many studies have shown that recurrent seizure risk is unrelated to seizure duration, a recurring generalized tonic-clonic status epilepticus episode is more likely to be a prolonged seizure.
    • Choose long-term treatment medications based on the patient's seizure type and EEG pattern. Knowledge of the seizure type and EEG pattern should help the physician confirm the diagnosis of an epileptic syndrome and improve selection of anticonvulsant medication.
  • Patients with partial seizures respond better overall to carbamazepine, phenytoin, and phenobarbital (infants). Valproic acid and phenobarbital are better treatments for patients with generalized tonic-clonic seizures, although carbamazepine and phenytoin can also be administered for patients with secondary generalized seizures. Valproic acid carries a higher risk of liver failure in patients younger than 2 years and those on polypharmacy.

Complications

  • The most feared complication of generalized tonic-clonic status epilepticus is brain damage associated with neuronal loss mediated by sustained EEG seizure activity.
  • Other complications described in patients who have had prolonged seizures include fluid, electrolyte, metabolic and disturbances; trauma; and cardiopulmonary problems.
    • Fluid, electrolyte, and metabolic complications include lactic acidosis, dehydration, and hypotension.
    • Myoglobinuria caused by muscle breakdown during a seizure may lead to renal dysfunction.
    • Craniofacial injuries include oral trauma, both internal (eg, biting the tongue or oral mucosa) and external (eg, hitting the lips). Many patients have also closed head or facial injuries during the clonic phase of seizures.
    • Pulmonary edema and cardiac arrhythmias may be complications of status epilepticus or its treatment.
  • Disseminated intravascular coagulation in association with significant leukocytosis and mild cerebrospinal fluid pleocytosis may produce a clinical picture similar to sepsis or CNS infection. In these cases, patients are often treated for a severe infection until sepsis or meningitis/encephalitis can be safely ruled out.
  • See phenobarbital in the Medication section for information on well-known complications associated with barbiturate-induced coma (ie, general anesthesia).

Prognosis

  • Generalized tonic-clonic status epilepticus seizures of less than 1-hour duration have a better prognosis than do those lasting longer.
  • Children have a much lower mortality rate after generalized tonic-clonic status epilepticus.
  • See Mortality/Morbidity for information on generalized tonic-clonic status epilepticus outcome, sequelae, morbidity, and mortality.
  • Patients with refractory status epilepticus who require high-dose suppressive therapy (eg, barbiturate coma, midazolam infusion) often need prolonged therapy. The long-term outcome in previously healthy children who survived prolonged barbiturate coma or midazolam infusion for status epilepticus is not particularly favorable. In one study performed at Boston Children's Hospital, all patients developed intractable epilepsy, and none returned to baseline.
  • De novo development of hippocampus sclerosis (ie, mesial temporal lobe sclerosis) is one of the possible complications of status epilepticus and possibly the reason why survivors may develop chronic recurrent and refractory complex partial seizures.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Every institution that treats patients who have generalized tonic-clonic status epilepticus (GTCSE) should have a treatment protocol. This protocol should be based on current information derived from authoritative sources, as well as on recent reviews of the literature, and the protocol should be communicated to the medical staff. Review treatment protocols at least annually.
  • Litigation is often based on perceptions that treatment deviated from established standards of practice. Because standards of practice can be difficult to define, physicians and institutions can avoid many legal problems by establishing and following institutional parameters for managing generalized tonic-clonic status epilepticus.
  • Seizure-related brain damage is another potential source of litigation in generalized tonic-clonic status epilepticus management.
    • Patients with epilepsy present at different ages, even when the etiology of their epilepsy is genetic or cryptogenic.
    • Although learning disabilities and mental retardation are more common among children with epilepsy than in the general population, cognitive problems often remain undiagnosed until the patient's first seizure and sometimes not until the first prolonged seizure. Physicians can occasionally obtain a history of abnormal language development and cognition prior to the seizures.
    • Once seizures are controlled in the emergency department (ED) or ICU and the patient is stabilized, the treating physician should (1) obtain a full history, including detailed developmental history, for documentation and (2) fully document procedures used to manage the episode, including all medications with doses and routes of administration. Physicians or nurses should also record vital signs, oxygen saturation, and ABG levels.
  • An example case discussion is as follows:
    • A 10-year-old boy who is obese and who has a history of grand mal seizures presents to the ED with a generalized tonic-clonic convulsion. By the time the patient is seen by an ED physician, the seizure has lasted 45 minutes. About 60 minutes after initial assessment, a venous cutdown is performed in the patient's right foot following several unsuccessful attempts to start an IV line. Next, the patient receives 2 doses of lorazepam, a loading dose of 20 mg/kg of fosphenytoin, and then 20 mg/kg of phenobarbital. The seizures persist, so the patient is transferred to the ICU. The boy's tonic-clonic activity finally stops in response to barbiturate anesthesia, 2 hours after onset. The patient is weaned successfully from the barbiturate anesthesia and is discharged from the hospital after 2 weeks. A neuropsychological assessment 6 months later shows a significant loss in the patient's memory scores compared with baseline scores obtained at the time his epilepsy was diagnosed.
    • At first glance, management of this case appears correct, with an appropriate sequence of anticonvulsant medications. However, waiting 45 minutes to start anticonvulsant therapy while attempting intravenous (IV) line insertion in a patient who already has been seizing for 1 hour is unacceptable. Rectal diazepam should have been initiated as soon as problems were encountered obtaining IV access. The finding of memory skill decline after such an event supports litigation against the treating physician, who could potentially be found liable for the delay in treatment.
 


More on Status Epilepticus

Overview: Status Epilepticus
Differential Diagnoses & Workup: Status Epilepticus
Treatment & Medication: Status Epilepticus
Follow-up: Status Epilepticus
Multimedia: Status Epilepticus
References
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Further Reading

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Keywords

status epilepticus, prolonged seizures, SE, generalized tonic-clonic status epilepticus, generalized tonic-clonic SE, GTCSE, nonconvulsive status epilepticus, nonconvulsive SE, NCSE, epilepsia partialis continua, complex partial and absence status epilepticus, simple partial status epilepticus, complex partial status epilepticus, epilepsy, seizures, violent seizures, hypoglycemia, head trauma, progressive encephalopathy, CNS lipid storage diseases, mitochondrial disorder, cerebral insult, electrolyte disturbance, zombie, hyperthermia, hypotension, periodic lateralizing epileptiform discharges, PLEDs, catscratch fever, meningitis, otitis media, pneumonia, lymphadenopathy, carbamazepine, tiagabine, treatment, diagnosis

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Contributor Information and Disclosures

Author

Marcio Sotero de Menezes, MD, Associate Professor, Department of Neurology, Division of Pediatric Neurology, Children's Hospital of Seattle, University of Washington
Marcio Sotero de Menezes, MD is a member of the following medical societies: American Academy of Neurology and American Epilepsy Society
Disclosure: Nothing to disclose.

Coauthor(s)

Ednea Simon, MD, Acting Assistant Professor, Department of Neurology, University of Washington
Ednea Simon, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, and Child Neurology Society
Disclosure: Nothing to disclose.

Medical Editor

G Patricia Cantwell, MD, Associate Clinical Professor, Department of Pediatrics, University of Miami; Director of Pediatric Critical Care Medicine, Miller School of Medicine, Jackson Children's Hospital
G Patricia Cantwell, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Barry J Evans, MD, Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center
Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

 
 
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