How are generalized tonic-clonic status epilepticus (SE) and subtle SE treated?

Updated: Feb 13, 2018
  • Author: Julie L Roth, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Both generalized tonic-clonic status epilepticus (SE) and subtle SE must be treated aggressively. Maintenance of vital signs, including respiratory function, is of major importance. Any indication of respiratory insufficiency should be addressed by intubation.

Early treatment measures are performed in concert with diagnostic studies. The treating physician should not wait for a blood level to return from a laboratory test before giving the patient a loading dose of phenytoin. The same protocol should be followed regardless of whether the patient is already taking phenytoin. Assume that the patient is noncompliant because this is the most common cause of SE in patients with known epilepsy.

Even if the patient has been compliant and even if phenytoin levels were already in the therapeutic range (10-20 µg/mL), data suggest that 20-30 µg/mL is more effective than 10-20 µg/mL in stopping seizures.

High doses can cause ataxia and sedation. Because the patient is likely to be hospitalized after the SE is controlled, these adverse effects are less important than they would be in a patient being treated on an outpatient basis. SE is a life-threatening situation, and the patient will be admitted to the hospital after treatment. Therefore, if treatment errs, it should err on the side of excessive medication. Temporary adverse effects are preferred to irreversible brain damage or death.

Finally, systemic acidosis is not a major concern because it is usually transient, and medical treatment to normalize acidosis can lead to a rebound metabolic alkalosis when the SE stops. In addition, evidence suggests that acidosis has antiseizure effects.

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