Gloucestershire Hospitals

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1 Gloucestershire Hospitals NHS Foundation Trust TRUST GUIDELINE EPILEPSY AND STATUS EPILEPTICUS MANAGEMENT 1. INTRODUCTION The aim of this guideline is to ensure safe management of Status Epilepticus in the Emergency Department and ACU, and the safe management of status epilepticus of tonic clonic seizures as recommended by NICE 2004 guidelines. Read this guideline in conjunction with the Management of Seizures care plan, First Fit Policy and Epilepsy and Pregnancy 2. DEFINITIONS Word/Term (9 point Arial bold) Status epilepticus Descriptor Any seizure lasting for at least 30 minutes or Repeated seizures lasting for a total of 30 minutes or longer, from which the person does not regain consciousness between each seizure. 3. ROLES AND RESPONSIBILITIES Post/Group Details Resources Review/ Monitoring Consultant Neurologist Responsibility for X X X X X X management of status epilepticus patients Provision of specialist advice to ED and ACU staff ITU staff Treatment of refractory Grades X X X X X status epilepticus patients 5-8 ACU/ED/Neurology medical/clinical staff Treatment of status epilepticus patients Referral to DCC if refractory state suspected or confirmed 4. MANAGEMENT OF STATUS EPILEPTICUS Grades Non Epileptic Attacks (previously referred to as Pseudo-status) Implementation Records Reporting HR X X X X X In non epileptic attacks motor activity may be evident, poor response to treatment, on/off pattern of seizure activity, there is lack of metabolic changes and the EEG and prolactin levels (within 20 minutes of seizure stopping) will be normal. 4.2 Phase I: Compensation 0-30minutes During this phase, cerebral metabolism is greatly increased because of seizure activity, but physiological mechanisms are sufficient to meet the metabolic demands and cerebral tissue is protected from hypoxia or metabolic damage. The major physiological changes are related to the greatly increased cerebral blood flow and metabolism, massive autonomic activity and cardiovascular changes. STATUS EPILEPTICUS MANAGEMENT V2.2 (Amended March 2013) PAGE 1 OF 6

2 Cerebral Changes Systemic and Metabolic Autonomic and Cardiovascular changes changes Increased blood flow Hyperglycaemia Hypertension Increased metabolism Lactic acidosis Increased cardiac output Energy requirements Increased central venous pressure matched by supply of oxygen and glucose (increased glucose and oxygen utilization) Increased lactate Massive catecholamine release concentration Increased glucose concentration Tachycardia Cardiac dysrhythmia Salivation Hyperpyrexia Vomiting Incontinence 4.3 Phase II: Decompensation 30 minutes and over During this phase, the greatly increased cerebral metabolic demands cannot be fully met, resulting in hypoxia and altered cerebral and systemic metabolic patterns. Autonomic changes persist and cardio respiratory functions may progressively fail to maintain homeostasis. Cerebral Changes Failure of cerebral autoregulation, thus cerebral blood flow becomes dependent on systemic blood pressure Systemic and Metabolic changes Consumptive coagulopathy, DIC (disseminated intravascular coagulopathy), multi-organ failure Autonomic and Cardiovascular changes Respiratory and cardiac impairment (pulmonary oedema, pulmonary embolism, respiratory collapse, cardiac failure, dysrhythmia) Hypoxia Hypoglycaemia Hyperpyrexia Hypoglycaemia Hyponatraemia Systemic hypoxia Falling lactate Hypokalaemia/ Falling blood pressure concentrations Hyperkalaemia Falling energy state Metabolic and respiratory Falling cardiac output acidosis Rise in intracranial pressure and cerebral oedema Hepatic and renal dysfunction Rhabdomolysis, myoglobulinuria Leucocytosis Note: The physiological changes listed above do not necessarily occur in all cases. The type and extent of the changes depend on aetiology, clinical circumstances and methods of therapy employed. Refer to Seizure Care Plan. STATUS EPILEPTICUS MANAGEMENT V2.2 (Amended March 2013) PAGE 2 OF 6

3 5. TREATMENT GUIDELINES FOR STATUS EPILEPTICUS IN ADULTS If seizure lasts for more than 5-10 minutes or repeated seizures occur with no regaining of consciousness. (Patients may have oral Clobazam or Clonazepam and or Buccal Midazolam or Rectal Diazepam to use at home first line) NB: If this patient is thought to be dying and in the last days/weeks of life, a different approach may be considered, see box below. If progresses Early (0-30 minutes) Early (0-30 minutes) Midazolam 2.5mg - 5mg IV bolus (In Elderly Patients 1-2.5mg IV) Repeat after 3-10 minutes if seizure persists Or Lorazepam to a maximum of 4mg IV bolus Repeat after minutes if seizure persists Or Diazepam 10mg IV bolus or rectally Repeat after minutes if seizure persists Maintain airway and give oxygen and monitor saturation levels ensure patient safety and dignity Monitor and record event Check history and initiate investigation if needed If progresses Established (30-60 minutes) Discuss with Senior Consultant Phenytoin IV infusion 15mg/kg at a rate not exceeding 50mg/minute (Cardiac Monitor during treatment) Or Phenobarbital IV infusion 10mg/kg (max. 1g) at 100mg/minute If progresses Refractory (over 60 minutes) Transfer to DCC Notes Check history of epilepsy, seizure type and description Check history of Non Epileptic Attack Disorder Check history of drug or alcohol abuse Investigate if no history of epilepsy Bloods - Glucose, U&E, Calcium, Magnesium, LFT, Gases and lactate, ph, FBC, culture, prolactin level, metabolic screen and correct accordingly If on Carbamazepine, Phenytoin or Phenobarbitone check levels but not for any other AED Urine - Toxicology Check temperature, neurological signs, haemodynamics, ECG, EEG Once seizure stopped turn patient into recovery position and observe closely Home once stable for 24 hours or back to normal seizure frequency Refer to Sue Higgins Epilepsy Specialist Nurse Tel: or written as per First Fit referral to review in clinic. Neurologist if A+E/ward review required For patients who are thought to be in the dying phase, a palliative approach is more appropriate. Consider stat Midazolam 5-10mg s/c for fitting and contact Specialist Palliative Care Team for advice on maintenance treatment. In hours GRH 5179, CGH 3447 and OOH ask for on-call Palliative Care Specialist via Switchboard. STATUS EPILEPTICUS MANAGEMENT V2.2 (Amended March 2013) PAGE 3 OF 6

4 5.1 Alternative Drug Regimes (Adult Doses) To be used after protocol has been followed under Consultant advice if seizures persist or patient hypersensitive to protocol regime. Clonazepam IV bolus/infusion 1mg over 2 minutes Lidocaine IV bolus/infusion mg/kg at <50mg/min (may repeat) Maintenance dose 3-4mg/kg/hour Lorazepam IV bolus/infusion 4mg 6. TRAINING To include all staff groups in the Emergency Department, ACU and Neurology to be updated annually by teaching session. 7. MONITORING OF COMPLIANCE Objective Frequency/timescale Methodology Monitoring treatment outcomes for status epilepticus patients Ongoing Review of relevant ACIs and annual report to Divisional Board. Exception monitoring of poor outcomes. 8. REFERENCES Chappell B, Crawford P. (2001) Epilepsy at your fingertips. London: Class Publishing. NICE Guidelines The Epilepsies: Diagnosis and management of the epilepsies in adults in primary and secondary care. London: NICE. Cockerell and Shorvon (1996). Epilepsy Current Concepts. London: CML. STATUS EPILEPTICUS MANAGEMENT V2.2 (Amended March 2013) PAGE 4 OF 6

5 STATUS EPILEPTICUS MANAGEMENT DOCUMENT PROFILE DOCUMENT PROFILE REFERENCE NUMBER A0089 CATEGORY Clinical VERSION 2.2 (amended March 2013) SPONSOR Dr Fuller, Consultant Neurologist AUTHOR Sue Higgins, Epilepsy Specialist Nurse (technical authoring support, Kym Ypres-Smith) ISSUE DATE November 2011 REVIEW DETAILS November 2014 review by Consultant Neurologist ASSURING GROUP Consultant Neurologists APPROVING GROUP Trust Policy Approval Group APPROVAL DETAILS 08/01/2013 D&T Meeting (minute 2.1) 08/11/ TPAG COMPLIANCE INFORMATION Compliance with NICE guideline (see below) CONSULTEES Consultant Neurologists: Dr Fuller, Dr Silva, Dr Martin, Dr Morrish; Acute Medicine Consultant: Dr Hauser DISSEMINATION DETAILS Upload to Policy Site; global ; cascaded via divisions KEYWORDS Status epilepticus RELATED TRUST DOCUMENTS Seizure Care Plan OTHER RELEVANT DOCUMENTS Management of Seizures care plan, First Fit Policy and Epilepsy and Pregnancy ASSOCIATED LEGISLATION AND CODES OF PRACTICE NICE Guidelines The Epilepsies: Diagnosis and management of the epilepsies in adults in primary and secondary care STATUS EPILEPTICUS MANAGEMENT V2.2 (Amended March 2013) PAGE 5 OF 6

6 Gloucestershire Hospitals NHS Foundation Trust EQUALITY IMPACT ASSESSMENT INITIAL SCREENING 1. Lead Name : Sue Higgins Job Title : Epilepsy Nurse Specialist 2. Is this a new or existing policy, service strategy, procedure or function? Existing 3. Who is the policy/service strategy, procedure or function aimed at? Staff - All Medical and Qualified Nursing staff 4. Are any of the following groups adversely affected by this policy: If yes is this high, medium or low impact (see attached notes): Disabled people: No Yes Race, ethnicity & nationality: No Yes Male/Female/transgender: No Yes Age, young or older people: No Yes Sexual orientation: No Yes Religion, belief & faith: No Yes If the answer is yes to any of these, proceed to full assessment. If the answer is no to all categories, the assessment is now complete. Date of assessment: Signature: Director: Completed by: Sue Higgins Job title: Epilepsy Nurse Specialist Signature: This EIA will be published on the Trust website. A completed EIA must accompany a new policy or a reviewed policy when it is confirmed by the relevant Trust Committee, Divisional Board, Trust Director or Trust Board. Executive Directors are responsible for ensuring that EIAs are completed in accordance with this procedure. STATUS EPILEPTICUS MANAGEMENT V2.2 (Amended March 2013) PAGE 6 OF 6