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<< Seizures and Status Epilepticus: Diagnosis and Management in the Emergency Department
Epidemiology
Seizure is a common presentation in the emergency department (ED), representing at least 1% to 2% of all ED visits.6, 7 Current estimates suggest that 6.6 of 1000 Americans in the general population will present to an ED after a seizure in a given year, accounting for approximately 2.5 million visits a year in the United States.8, 9 A seizure is often a secondary manifestation of a broad range of etiologies. Generalized convulsive status epilepticus (GCSE) affects from 50,000 to 150,000 patients every year. These patients are critically ill, with mortality estimates ranging from 10 to 40%.10, 11, 12
In the US population, the prevalence of active epilepsy is approximately 6 per 1000; one-quarter to one-half of patients with epilepsy continue to have recurrent seizures despite therapy.13 Even under optimal circumstances, excluding noncompliance and other variables, 5 to 10% of patients have intractable epilepsy despite pharmacologic management.14
The incidence of epilepsy matches the underlying etiology. It is high in the first year of life and then decreases throughout childhood, remaining relatively stable and low throughout mid-life. At age 55, the incidence begins to increase, peaking in persons 75 years and older. 15 Partial epilepsies, in particular, increase in the elderly paralleling the increased incidence of degenerative, neoplastic, and vascular pathologies.
Estimates of the incidence of status epilepticus vary widely, and may have changed over the years. A review of a California hospitalization database through the 1990’s revealed an overall incidence rate of 6.2 per 100,000 people in the general population, with a decreasing incidence trend through the study period.16 In that study, the highest incidence was found in those over the age of 75 (22/100,000). A Virginia study found an overall incidence rate as high as 29 per 100,000.12
In one prospective study, over half of patients presenting to the ED in status epilepticus had no prior seizure history.12 Overall mortality due to status epilepticus ranges from 10 to 40% depending on the study, and seems to be closely related to the underlying etiology. 17, 16, 18, 19, 20 Fatality rates for patients with SE caused by anoxic brain injury and CNS infection is 64% and 32% respectively, but the rate in those with status epilepticus as a primary diagnosis without other identified co-morbidities is only 3.5%.16 Long term mortality is also increased in patients who experience an episode of status epilepticus, with a 10 year mortality that is 2.8 times that of the general population.21 In addition to mortality, an additional 5-10% of people experiencing status epilepticus have permanent sequelae, such as a permanent vegetative state or cognitive difficulties.22
Prolonged SE is associated with worse outcomes and is thought to be due to both the primary cause of status as well as secondary systemic effects, such as hypoxia, metabolic acidosis, hyperthermia, hypoglycemia which results in dysrhythmias, rhabdomyolysis, pulmonary edema, and DIC.23 SE is harder to terminate with continued activity.24, 25 Patients treated within one hour of continuous seizure activity had an 80% likelihood of termination vs. 40 to 50% likelihood in patients in which treatment was initiated after two or more hours.23
In the US population, the prevalence of active epilepsy is approximately 6 per 1000; one-quarter to one-half of patients with epilepsy continue to have recurrent seizures despite therapy.13 Even under optimal circumstances, excluding noncompliance and other variables, 5 to 10% of patients have intractable epilepsy despite pharmacologic management.14
The incidence of epilepsy matches the underlying etiology. It is high in the first year of life and then decreases throughout childhood, remaining relatively stable and low throughout mid-life. At age 55, the incidence begins to increase, peaking in persons 75 years and older. 15 Partial epilepsies, in particular, increase in the elderly paralleling the increased incidence of degenerative, neoplastic, and vascular pathologies.
Estimates of the incidence of status epilepticus vary widely, and may have changed over the years. A review of a California hospitalization database through the 1990’s revealed an overall incidence rate of 6.2 per 100,000 people in the general population, with a decreasing incidence trend through the study period.16 In that study, the highest incidence was found in those over the age of 75 (22/100,000). A Virginia study found an overall incidence rate as high as 29 per 100,000.12
In one prospective study, over half of patients presenting to the ED in status epilepticus had no prior seizure history.12 Overall mortality due to status epilepticus ranges from 10 to 40% depending on the study, and seems to be closely related to the underlying etiology. 17, 16, 18, 19, 20 Fatality rates for patients with SE caused by anoxic brain injury and CNS infection is 64% and 32% respectively, but the rate in those with status epilepticus as a primary diagnosis without other identified co-morbidities is only 3.5%.16 Long term mortality is also increased in patients who experience an episode of status epilepticus, with a 10 year mortality that is 2.8 times that of the general population.21 In addition to mortality, an additional 5-10% of people experiencing status epilepticus have permanent sequelae, such as a permanent vegetative state or cognitive difficulties.22
Prolonged SE is associated with worse outcomes and is thought to be due to both the primary cause of status as well as secondary systemic effects, such as hypoxia, metabolic acidosis, hyperthermia, hypoglycemia which results in dysrhythmias, rhabdomyolysis, pulmonary edema, and DIC.23 SE is harder to terminate with continued activity.24, 25 Patients treated within one hour of continuous seizure activity had an 80% likelihood of termination vs. 40 to 50% likelihood in patients in which treatment was initiated after two or more hours.23
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