Status epilepticus. A perspective from the neuroscience intensive care unit

Area of Science:

• Neurology
• Critical Care Medicine

Background:

• Status epilepticus (SE), encompassing generalized convulsive SE (GCSE) and non-convulsive SE (NCSE), frequently presents in emergency departments and NICUs.
• While GCSE is common in emergency departments, NCSE is more prevalent in NICUs. GCSE can evolve into NCSE due to prolonged seizures or incomplete treatment.

Observation:

• Acute cerebral injuries are common in SE patients, irrespective of prior epilepsy history, and are almost definitional in NICU patients.
• SE progresses through stages, potentially leading to refractory SE, neuronal necrosis, and permanent brain damage.
• Treatment responsiveness is time-dependent, highlighting the critical 60-minute window for effective SE control.

Findings:

• Access to SE treatment protocols is a critical, overlooked barrier to improving outcomes, particularly in emergency settings.
• Early diagnosis in NICUs, often requiring a high index of suspicion and continuous EEG monitoring for NCSE, is key as access is less problematic.
• NICU patients may be more vulnerable to SE due to pre-existing cerebral injuries, making expedited treatment imperative.

Implications:

• Addressing access barriers in emergency departments is essential for optimizing SE treatment algorithms.
• Prompt diagnosis and management, including supportive care and appropriate first-line medications like lorazepam or diazepam-phenytoin, are vital.
• High-dose intravenous midazolam shows promise as an alternative for refractory SE, complementing established treatments like barbiturate coma.