Generalized Status Epilepticus 

A seizure lasting longer than 5 mins or without return to baseline between ictal events
The longer its allowed to go on, the harder it is to treat, as the neurological tissue becomes refractory

DDx
- Structural: tumor
- Vascular: ischemia, venous sinus thrombosis
- Electrical: epileptic
- Metabolic: hypoglycemia, hypocalcemia, hyponatremia, thyrotoxicosis
- Infectious: systemic infections, CNS infections esp HSV encephalitis (prefers to affect temporal lobes, which are epileptogenic)
- Withdrawal or overdose (theophylline, demerol, some antibiotics)
- Nutritional

Tx: (Dr.A's protocol)

First, airway/breathing/circulation/accucheck (or empiric 50mL amp of D50), 100mg of thiamine, consider 1mg naloxone if you think there is a risk of opiate tox

1. Abortive - IV Ativan at 2mg increments to a max of 7-8mg; IV Valium is second line. The more benzos you give, the more you have to contend with the possibility of losing the airway and having to intubate.

2. If the seizure doesn't break immediately with the first 2mg push of IV ativan, load with fosphenytoin 15 mg PE/kg (PE= phenytoin equivalent) or 18mg/kg phenytoin and then decide whether to give more benzos.
- Note: Fosphenytoin can be pushed 3x faster than phenytoin (150mg/min vs 50mg/min). Dilantin pushed fast = risk of cardiac dysrhythmias, hemodynamic instability, tissue necrosis with extravasation. Fospheny has a lower risk of all these complications.
- Never mix dilantin with dextrose solution (increases risk of precipitation), always mix with normal saline
- If someone is allergic to dilantin, load with Vimpat ($$$) or Depakote.

3. If the seizure still didn't break after you completed loading with dilantin/fosphenytoin, then intubate and induce coma, with the goal of flatline EEG for 24-48 hours.
- Ideally, induce AND maintain with pentobarb, but its often not available on short notice
- If pentobarb unavail, induce with versed or propofol and maintain with pentobarb
- Can't maintain with versed -- it requires huge (and ever-increasing) doses to keep on for longer than 12-24 hrs, and can't maintain with propofol, due to risk of propofol infusion syndrome - high doses for prolonged time period (>1-3 days) leads to cardiac/renal failure, rhabdo, acidosis.
- Second line maintenance agent: phenobarb: very long half life ~3 days. Preferred for humans seizing 2/2 tumors. Interesting factoid: this is the agent of choice for dogs with seizures.

Other potential treatments that are less-used/more unorthodox for if everything else fails:
- ketamine
- ketogenic diet
- ECT
- plasma exchange - if the suspected etiology is autoimmune/paraneoplastic or something else plasma exchangeable
- focal surgery

Weaning off pentobarb-- goal of therapeutic levels of 2-3 AEDs of differing classes and mechanism of action (ie. dilantin/vimpat/depakote)

Long term AED: for patients that are clinically high-performing and doing well with a good EEG, can consider wean at 1-2 months, otherwise the AED cocktail should be continued