Jordan K G
St. Bernardine Neuroscience Center, San Bernardino, California.
Neurosurg Clin N Am. 1994 Oct;5(4):671-86.
Patients with GCSE and NCSE are common and may present to the emergency department or the NICU. In the NICU, NCSE is a more common presentation than GCSE. In the emergency department, GCSE commonly evolves to NCSE, either as a late sequela of prolonged SE or due to partial treatment with antiepileptic medication or neuromuscular blocking agents. In the emergency department, acute cerebral injuries are commonly found in patients presenting with SE, regardless of whether they have preexisting epilepsy. In the NICU, almost by definition, SE occurs in patients with acute cerebral injuries. Status epilepticus has been found to evolve sequentially through several stages, the end-point of which is a condition of refractory SE leading to neuronal necrosis and permanent cerebral injury. The responsiveness of SE to treatment is time-dependent. This makes early diagnosis and initiation of treatment essential. Most published treatment algorithms stress a 60-minute time window from the diagnosis of SE to its successful control. Unfortunately, the practical problem of patients with SE accessing such treatment protocols has been overlooked. Our preliminary (unpublished) data suggest that this access problem must be solved for treatment algorithms to improve the outcome of SE. In the NICU, access is less of a problem, and the determining factor is early diagnosis by NICU personnel. Because these patients usually sustain NCSE, which can be difficult to diagnose, a high index of suspicion and, optimally, continuous EEG monitoring are necessary for early diagnosis. NICU patients may be more susceptible to the ravages of SE because of their preexisting cerebral injuries. Expedited treatment may therefore be more important in this patient group. Clinical management of SE requires meticulous attention to ventilation and oxygenation, maintenance of adequate blood pressure, prevention of hyperthermia, and close monitoring for cardiac abnormalities. No specific medication is ideal for controlling SE. The knowledgeable and prompt use of intravenous lorazepam, a diazepam-phenytoin combination, or phenobarbital is acceptable as first-line treatment and as part of a systematic treatment algorithm. Refractory SE has been treated conventionally with high-dose intravenous barbiturate coma. Recent evidence suggests that high-dose intravenous midazolam may provide a useful alternative.
全身性惊厥性癫痫持续状态（GCSE）和非惊厥性癫痫持续状态（NCSE）的患者很常见，可能会前往急诊科或新生儿重症监护病房（NICU）就诊。在NICU中，NCSE比GCSE更常见。在急诊科，GCSE通常会演变为NCSE，这要么是长时间癫痫持续状态（SE）的晚期后遗症，要么是由于使用抗癫痫药物或神经肌肉阻滞剂进行部分治疗所致。在急诊科，无论患者是否有既往癫痫病史，急性脑损伤在出现SE的患者中都很常见。在NICU中，几乎根据定义，SE发生在急性脑损伤患者中。已发现癫痫持续状态会依次经历几个阶段，其终点是难治性SE状态，导致神经元坏死和永久性脑损伤。SE对治疗的反应具有时间依赖性。这使得早期诊断和开始治疗至关重要。大多数已发表的治疗算法强调从SE诊断到成功控制的60分钟时间窗。不幸的是，SE患者获得此类治疗方案的实际问题被忽视了。我们初步的（未发表）数据表明，为了改善SE的治疗结果，必须解决这个获得治疗的问题。在NICU中，获得治疗的问题较小，决定因素是NICU人员的早期诊断。因为这些患者通常患有NCSE，而NCSE可能难以诊断，所以高度的怀疑指数以及最佳情况下的持续脑电图监测对于早期诊断是必要的。NICU患者由于其既往的脑损伤可能更容易受到SE的破坏。因此，快速治疗在该患者群体中可能更为重要。SE的临床管理需要精心关注通气和氧合、维持足够的血压、预防体温过高以及密切监测心脏异常情况。没有一种特定的药物对于控制SE是理想的。明智且迅速地使用静脉注射劳拉西泮、地西泮 - 苯妥英联合用药或苯巴比妥作为一线治疗以及作为系统治疗算法的一部分是可以接受的。难治性SE传统上用大剂量静脉注射巴比妥类药物诱导昏迷进行治疗。最近的证据表明，大剂量静脉注射咪达唑仑可能提供一种有用的替代方法。
