Status epilepticus: review on diagnosis, monitoring and treatment.

Status epilepticus (SE) is a frequent neurological emergency associated with high morbidity and mortality. According to the new ILAE 2015 definition, SE results either from the failure of the mechanisms responsible for seizure termination or initiation, leading to abnormally prolonged seizures. The definition has different time points for convulsive, focal and absence SE. Time is brain. There are changes in synaptic receptors leading to a more proconvulsant state and increased risk of brain lesion and sequelae with long duration. Management of SE must include three pillars: stop seizures, stabilize patients to avoid secondary lesions and treat underlying causes. Convulsive SE is defined after 5 minutes and is a major emergency. Benzodiazepines are the initial treatment, and should be given fast and an adequate dose. Phenytoin/fosphenytoin, levetiracetam and valproic acid are evidence choices for second line treatment. If SE persists, anesthetic drugs are probably the best option for third line treatment, despite lack of evidence. Midazolam is usually the best initial choice and barbiturates should be considered for refractory cases. Nonconvulsive status epilepticus has a similar initial approach, with benzodiazepines and second line intravenous (IV) agents, but after that, aggressiveness should be balanced considering risk of lesion due to seizures and medical complications caused by aggressive treatment. Usually, the best approach is the use of sequential IV antiepileptic drugs (oral/tube are options if IV options are not available). EEG monitoring is crucial for diagnosis of nonconvulsive SE, after initial control of convulsive SE and treatment control. Institutional protocols are advised to improve care.

Status epilepticus: review on diagnosis, monitoring and treatment / Estado de mal epiléptico: revisão sobre diagnóstico, monitorização e tratamento

Abstract Status epilepticus (SE) is a frequent neurological emergency associated with high morbidity and mortality. According to the new ILAE 2015 definition, SE results either from the failure of the mechanisms responsible for seizure termination or initiation, leading to abnormally prolonged seizures. The definition has different time points for convulsive, focal and absence SE. Time is brain. There are changes in synaptic receptors leading to a more proconvulsant state and increased risk of brain lesion and sequelae with long duration. Management of SE must include three pillars: stop seizures, stabilize patients to avoid secondary lesions and treat underlying causes. Convulsive SE is defined after 5 minutes and is a major emergency. Benzodiazepines are the initial treatment, and should be given fast and an adequate dose. Phenytoin/fosphenytoin, levetiracetam and valproic acid are evidence choices for second line treatment. If SE persists, anesthetic drugs are probably the best option for third line treatment, despite lack of evidence. Midazolam is usually the best initial choice and barbiturates should be considered for refractory cases. Nonconvulsive status epilepticus has a similar initial approach, with benzodiazepines and second line intravenous (IV) agents, but after that, aggressiveness should be balanced considering risk of lesion due to seizures and medical complications caused by aggressive treatment. Usually, the best approach is the use of sequential IV antiepileptic drugs (oral/tube are options if IV options are not available). EEG monitoring is crucial for diagnosis of nonconvulsive SE, after initial control of convulsive SE and treatment control. Institutional protocols are advised to improve care.

RESUMO O estado de mal epiléptico (EME) é uma emergência frequente, com alta morbi-mortalidade. Segundo nova definição da ILAE de 2015, EME acontece pela falha dos mecanismos responsáveis ​​pelo término ou início das crises, sendo anormalmente prolongadas. Pela definição existem diferentes tempos entre EME convulsivo, focal e ausência. Tempo é cérebro. Ocorrem alterações nos receptores sinápticos, levando estado mais pró-convulsivante, com aumento risco de lesão cerebral e sequelas. O manejo do EME deve incluir três pilares: parar a crise, estabilizar o paciente para evitar lesão secundária e tratar a etiologia. EME convulsivo é definido quando duração é maior que 5 minutos e trata-se grande emergência. Os benzodiazepínicos são o tratamento inicial, devem ser administrados rapidamente e na dose adequada. Fenitoína/fosfenitoína, levetiracetam e ácido valpróico são opções com evidência para tratamento de segunda linha. Se EME persistir, uso dos anestésicos é provavelmente a melhor opção como terceira linha tratamento, apesar da falta de evidências adequadas. O midazolam costuma ser a melhor escolha inicial e os barbitúricos devem ser considerados para casos refratários. O EME não convulsivo tem abordagem inicial semelhante, com benzodiazepínicos e agentes segunda linha, mas após, a agressividade deve ser equilibrada considerando risco de lesão pelas crises e complicações pelo tratamento agressivo. A abordagem sugerida é uso de fármacos IV sequenciais (via oral/tubo quando opções IV não disponíveis). A monitorização por EEG é fundamental para o diagnóstico do EME não convulsivo, após controle inicial EME convulsivo e para controle do tratamento. Protocolos institucionais são recomendados.