373.1 🎓 醫孞生版

373.1.0.1 📌 䞀頁重點

373.1.0.1.1 Definitions

373.1.1 Operational (ILAE 2015)

  • Time 1 (t1): time at which treatment should begin
    • Convulsive: 5 min
    • Focal with impaired awareness: 10 min
    • Absence: 10-15 min
  • Time 2 (t2): time after which permanent injury likely
    • Convulsive: 30 min
    • Focal: 60 min

373.1.2 Practical Definition

  • ≥ 5 min seizure activity, OR
  • ≥ 2 seizures without recovery of consciousness in between

373.1.3 Categories

Convulsive SE (CSE): - GTC most common - May evolve to subtle CSE (only minor motor activity)

Non-Convulsive SE (NCSE): - Altered consciousness without prominent motor - Diagnosed on EEG - Often missed clinically - 8-37% of ICU comatose patients

Focal SE: - Without impaired awareness (e.g., epilepsia partialis continua) - With impaired awareness

373.1.3.0.1 Etiology

373.1.4 Most Common

  • Low ASM levels (subtherapeutic, missed doses) — # 1 in known epilepsy
  • Withdrawal (alcohol, benzodiazepines)
  • CNS infection (meningitis, encephalitis)
  • Stroke (acute)
  • Traumatic brain injury
  • Metabolic: hyponatremia, hypoglycemia, hypocalcemia, uremia, hepatic encephalopathy
  • Drug toxicity (cocaine, MDMA, theophylline, INH)
  • Autoimmune encephalitis (NMDA-R, others)
  • Hypoxic-ischemic (post-cardiac arrest)
  • Brain tumor
373.1.4.0.1 Mortality
  • ~ 10-20% overall
  • Higher with:
    • Older age
    • Acute symptomatic etiology (anoxic > stroke > metabolic > infection)
    • Duration > 1 hr
    • Refractory SE: 30-50%
    • Super-refractory: 50%+
373.1.4.0.2 Treatment (Staged Algorithm)

373.1.5 Stage 1: Stabilization (0-5 min)

  • ABCs: airway, breathing, circulation
  • Position on side, protect from injury
  • IV access
  • Glucose check + dextrose if low (50 mL D50W) + thiamine 100 mg IV (before glucose if possible)
  • Vital signs
  • Labs: electrolytes, calcium, magnesium, glucose, ASM levels, toxicology, ABG
  • Initial workup: identify precipitant

373.1.6 Stage 2: First-Line — Benzodiazepines (5-20 min)

  • IV lorazepam 0.1 mg/kg (typical 4 mg) — preferred
  • IV diazepam 0.15-0.2 mg/kg (10 mg) — quick onset, shorter duration
  • IM midazolam 10 mg — if no IV (RAMPART trial)
  • Buccal/intranasal midazolam — pediatric/out-of-hospital
  • Rectal diazepam — alternative

May repeat once if no response.

373.1.7 Stage 3: Second-Line ASM (20-40 min)

ESETT trial (2019) — three options comparable, each ~ 50% effective: - IV levetiracetam 60 mg/kg (max 4500 mg) — preferred (fewer side effects) - IV fosphenytoin 20 mg PE/kg - IV valproate 40 mg/kg (max 3000 mg)

Other options: - IV phenobarbital (older, more sedating) - IV lacosamide (added in some protocols)

373.1.8 Stage 4: Refractory SE — Anesthesia (> 40 min)

  • Intubate + ICU
  • Continuous EEG monitoring
  • Choose one:
    • Midazolam infusion: 0.2 mg/kg load, 0.05-2 mg/kg/h
    • Propofol infusion: 1-2 mg/kg load, 30-200 ÎŒg/kg/min (PRIS risk with high dose)
    • Pentobarbital: 5-10 mg/kg load, 0.5-5 mg/kg/h
  • Goal: seizure suppression or burst-suppression on EEG
  • Continue 24-48 hr seizure free, then wean

373.1.9 Stage 5: Super-Refractory SE (> 24 hr)

  • Persistent or recurrent despite anesthesia
  • Add other ASMs
  • Ketogenic diet
  • Ketamine (NMDA antagonist)
  • Hypothermia
  • Immunotherapy if autoimmune suspected (IVIG, methylprednisolone, rituximab, cyclophosphamide, plasmapheresis)
  • ECT (case reports)
  • Vagus nerve stimulation
  • Identify and treat underlying cause
373.1.9.0.1 Special Considerations

373.1.10 Non-Convulsive SE (NCSE)

  • Often missed
  • Altered consciousness without obvious convulsions
  • cEEG essential (8-37% of ICU comatose have NCSE)
  • Treat similar to CSE but generally less aggressive (avoid anesthesia if just NCSE in well-tolerated patient)

373.1.11 Epilepsia Partialis Continua

  • Continuous focal motor seizures
  • Often Rasmussen encephalitis, MELAS, stroke
  • Difficult to treat
  • ASMs, immunotherapy if autoimmune

373.1.12 Absence SE

  • Continuous altered awareness
  • 3 Hz spike-wave EEG
  • Treatment: IV BZD + valproate

373.1.13 Anti-NMDA-R Encephalitis SE

  • Young women, paraneoplastic (ovarian teratoma) or post-viral
  • Psychiatric + seizures + movement + autonomic
  • Look for tumor (CT/MRI chest, pelvis)
  • Treatment: tumor removal + IVIG/steroids/rituximab/cyclophosphamide

373.1.14 Eclampsia

  • Pregnancy + HTN + seizures
  • Magnesium sulfate 4-6 g IV load + 1-2 g/h
  • Delivery is definitive
373.1.14.0.1 Workup During SE
  • Glucose, electrolytes, Ca, Mg
  • ASM levels
  • ABG (lactate often elevated)
  • CBC, LFTs, renal
  • Toxicology
  • Pregnancy test
  • ECG
  • CT head urgent (rule out hemorrhage)
  • MRI brain if no clear cause
  • LP if meningitis suspected (after imaging)
  • Specific antibody panels if autoimmune
  • EEG (continuous)
373.1.14.0.2 Post-SE Care
  • Identify underlying cause
  • Optimize ASMs (long-term)
  • Continuous EEG monitoring until stable
  • Address complications:
    • Rhabdomyolysis (CK + fluids)
    • Aspiration pneumonia
    • Hyperthermia
    • Lactic acidosis
    • Hyperkalemia
    • Cardiac arrhythmias
    • Hypotension from sedatives

373.1.14.1 🩺 床邊速查

  • SE = ≥ 5 min seizure OR ≥ 2 without recovery
  • Stage 1 (0-5 min): ABCs + glucose/thiamine + IV
  • Stage 2 (5-20 min): BZD — IV lorazepam 4 mg or IM midazolam 10 mg
  • Stage 3 (20-40 min): Levetiracetam, fosphenytoin, or valproate (ESETT 2019 comparable)
  • Stage 4 (> 40 min): Anesthesia — midazolam, propofol, or pentobarbital + cEEG + intubate
  • Stage 5 (> 24 hr super-refractory): combination + ketogenic + ketamine + immunotherapy
  • Eclampsia: magnesium sulfate + delivery
  • Anti-NMDA-R encephalitis: immunotherapy + tumor search
  • NCSE common in ICU comatose — cEEG essential
  • Mortality: 10-20% overall, refractory 30-50%