Status Epilepticus in the Emergency Department, Part 2: Treatment
Two pharmacologic agents that have some limited efficacy include lacosamide and topiramate. Isoflurane is the most commonly used inhaled anesthetic.27 Thiopental and pentobarbital are barbiturate anesthetics which are used in super refractory GCSE. Barbiturates have a desirable theoretical neuroprotective effect, but are limited by their CV depression at high doses.28 Vagus nerve stimulation, induced hypothermia, transcranial magnetic stimulation, and neurosurgical intervention have all been attempted with varying degrees of success in select patients.29
Eclampsia and Seizures During Pregnancy
Treating a pregnant patient with status epilepticus presents a unique challenge in the ED. The EP must weigh the importance of aborting seizure activity with the possibility of teratogenic effects. All AEDs must be used carefully, but valproic acid and phenytoin are potent teratogens and should be avoided in this patient population. Most evidence points to safety with exposure to benzodiazepines during pregnancy.30 Eclampsia must be considered in patients who may be pregnant or recently pregnant; magnesium should be used with or without the use of benzodiazepines in these patients.
Summary
The diagnosis and treatment of status epilepticus in the ED can be challenging. While there is a multitude of first-, second-, and third-line agents available to treat this condition, choosing the correct therapy for a patient can be daunting, and evidence of which treatment is superior can be lacking. However, the judicious use of benzodiazepines continues to be the primary treatment option. If status epilepticus persists, alternative agents and airway management may be necessary. The goal of treatment is to abort seizure-like activity observed on physician examination or EEG. It is important to remember that symptoms of status epilepticus can be subtle (eg, mild twitching, eye deviation), particularly when airway management is required since neuromuscular blockade can mask overt symptoms. Consultation with neurology and critical care colleagues should be initiated early; when such consultation is not available, the EP should consider patient transfer to an appropriate facility.
