Emergency Neurological Life Support: Status Epilepticus

Abstract

Patients with prolonged or rapidly recurring convulsions lasting more than 5 min are in status epilepticus (SE) and require immediate resuscitation. Although there are relatively few randomized clinical trials, available evidence and experience suggest that early and aggressive treatment of SE improves patient outcomes, for which reason this was chosen as an Emergency Neurological Life Support protocol. The current approach to the emergency treatment of SE emphasizes rapid initiation of adequate doses of first-line therapy, as well as accelerated second-line anticonvulsant drugs and induced coma when these fail, coupled with admission to a unit capable of neurological critical care and electroencephalography monitoring. This protocol will focus on the initial treatment of SE but also review subsequent steps in the protocol once the patient is hospitalized.

Valproate Protein Binding Is Highly Variable in ICU Patients and Not Predicted by Total Serum Concentrations: A Case Series and Literature Review

“…Our data highlight the potential benefit of monitoring free serum valproate concentrations in critically ill patients, and increase the reported cases in the ICU literature nearly 5‐fold. This finding is important because valproate is a preferred agent for seizure control and an emerging option for the management of ICU agitation . One report suggests that valproate may be more effective (75%) than phenytoin (59%) or levetiracetam (52%) to control status epilepticus .…”

“…Several clinical factors common in the ICU are associated with higher free fractions of valproate including uremia, hypoalbuminemia, free fatty acid administration (e.g., Intralipid, propofol, or clevidipine), and drug‐drug interactions resulting in competition for albumin binding sites (e.g., aspirin and ibuprofen) . Although documented more than 30 years ago, the potential utility of monitoring free serum valproate concentrations is not mentioned in clinical reviews or guidelines, and few ICU reports have been published . More than 10 years ago, a formula to adjust total valproate concentrations was proposed because only 2% of laboratories were measuring free concentrations, but our data suggest this formula is unreliable in ICU patients.…”

“…Valproate protein binding has been understudied; we are aware of only four reported cases of free valproate monitoring in intensive care unit (ICU) patients . Reviews and guidelines recommend monitoring serum valproate concentrations but make sparse or no mention of free serum concentration monitoring or altered protein binding …”

Autoimmune Encephalitis at the Neurological Intensive Care Unit: Etiologies, Reasons for Admission and Survival

“…Patients with AE often develop life-threatening complications that necessitate intensive care unit (ICU) admission [9, 10]. Notably, while ICU admission has been shown to be associated with poor outcome, little is known about clinical presentations and radiological and laboratory findings of those patients admitted to the ICU.…”

Predictive Value of the Bispectral Index for Burst Suppression on Diagnostic Electroencephalogram During Drug-Induced Coma

“…EEG and EEG-derived monitoring are well supported by the available evidence for monitoring effectiveness of therapies in managing status epilepticus to determine clinical end points (Claassen, Silbergleit, Weingart, & Smith, 2012). Continuous EEG monitoring, as available, is routinely utilized to guide barbiturate titration to EEG burst suppression in real time for managing intracranial hypertension (Sutter, Stevens, & Kaplan, 2013).…”