EFNS guideline on the management of status epilepticus in adults

Abstract

The objective of the current article was to review the literature and discuss the degree of evidence for various treatment strategies for status epilepticus (SE) in adults. We searched MEDLINE and EMBASE for relevant literature from 1966 to January 2005 and in the current updated version all pertinent publications from January 2005 to January 2009. Furthermore, the Cochrane Central Register of Controlled Trials (CENTRAL) was sought. Recommendations are based on this literature and on our judgement of the relevance of the references to the subject. Recommendations were reached by informative consensus approach. Where there was a lack of evidence but consensus was clear, we have stated our opinion as good practice points. The preferred treatment pathway for generalised convulsive status epilepticus (GCSE) is intravenous (i.v.) administration of 4-8 mg lorazepam or 10 mg diazepam directly followed by 18 mg/kg phenytoin. If seizures continue more than 10 min after first injection, another 4 mg lorazepam or 10 mg diazepam is recommended. Refractory GCSE is treated by anaesthetic doses of barbiturates, midazolam or propofol; the anaesthetics are titrated against an electroencephalogram burst suppression pattern for at least 24 h. The initial therapy of non-convulsive SE depends on type and cause. Complex partial SE is initially treated in the same manner as GCSE. However, if it turns out to be refractory, further non-anaesthetising i.v. substances such levetiracetam, phenobarbital or valproic acid should be given instead of anaesthetics. In subtle SE, in most patients, i.v. anaesthesia is required.

Nonconvulsive status epilepticus: a diagnostic and therapeutic challenge in the intensive care setting

“…These doses are repeated in case of persistence or recurrence of epileptic activity. If necessary, additional phenytoin (15 18 mg/kg) or equivalent fosphenytoin is recommended [Meierkord et al 2010;Tomson et al 1986]. Alternatively, levetiracetam at 30 40 mg/kg or valproic acid at 25 45 mg/kg may be administered rapidly [Shorvon et al 2008].…”

“…Consequently, current treatment options are still unsatisfactory, and mortality and morbidity rates remain high. However, in a number of areas, progress has been made including agreed upon guidelines [Meierkord et al 2010;Minicucci et al 2006] and consensus recommendations [Shorvon et al 2008;van Rijckevorsel et al 2006] on the management of the condition.…”

Purple Glove Syndrome after Phenytoin or Fosphenytoin Administration: Review of Reported Cases and Recommendations for Prevention

“…In this situation, an oral or parenteral loading dose is often administered. Patients presenting with status epilepticus refractory to benzodiazepine administration require prompt IV phenytoin administration [2,7,8]. Finally, patients with traumatic intracranial injury or symptomatic mass lesions are frequently prescribed with phenytoin for prophylaxis against seizure activity in either oral or parenteral form [9][10][11].…”

“…Mahajan et al reported a case of rapidly progressing distal limb ischemia resulting in compartment syndrome with arterial occlusion and thrombosis [31]. Finally, alternative drug regimens should be considered in situations in which efficacy has been shown to be non-inferior to phenytoin [2,10,60]. Any intravenous insertion sites should be monitored closely for pain, signs of extravasation, discoloration, or changes in perfusion and documented thoroughly [1,3].…”

“…It is recommended by the Epilepsy Foundation of America (EFA) and European Federation of Neurological Societies (EFNS) practice guidelines as the second-line agent for treatment of status epilepticus after IV benzodiazepines [2]. Phenytoin has been associated with a number of serious adverse drug reactions (ADR) including hypotension and arrhythmias with rapid IV administration, dermatologic reactions ranging from rashes to StevensJohnson syndrome or toxic epidermal necrolysis, severe hepatotoxicity, and other hypersensitivity events [3].…”