État de mal épileptique convulsif généralisé de l'adulte en situation d'urgence et en réanimation

Generalized convulsive status epilepticus (GCSE) must be rapidly identified and managed according to pre-established protocols developed by the teams that treat such patients. Close collaboration between emergency specialists, critical-care specialists, electrophysiologists and neurologists is essential. Overt GCSE, by far the most frequent, is generally easy to diagnose: it must nonetheless be distinguished from pseudo-status epilepticus. Subtle GCSE is difficult to recognize. The initial anti-epileptic treatments are fairly well classified but their efficacy is unreliable. If the patient is treated within 5 to 30 minutes after convulsions begin, clonazepam should be administered alone; if the convulsions persist, follow it 5 minutes later with a second injection of clonazepam together with phosphenytoin or phenobarbital. If convulsions began more than 30 minutes before treatment, the initial clonazepam dose should be combined with phosphenytoin or phenobarbital. Relay anti-epileptic treatment is essential in the short-term as well, unless the cause is immediately reversible. This relay must be immediate if diazepam or midazolam is used alone, because of the high risk of recurrence. Refractory GCSE must be diagnosed very cautiously. Its treatment requires resuscitation using anesthetic agents guided if possible by continuous electroencephalography (EEG), without ever stopping the basic anti-epileptic treatment. The cerebral aggression that results from either the status epilepticus itself or its cause must be treated with precision. Treatment of the cause is primordial and, when possible, always the main priority. The etiological investigation must be conducted with tenacity, speed, and perspicacity. GCSE may occur in known epileptics or be the first presentation. The investigation will be negative in 5-10% of cases. Although sometimes difficult to interpret, EEG is essential in numerous situations, in particular, atypical clinical pictures, vigilance disorders that persist after convulsions, and refractory status epilepticus. Overall, mortality is on the order of 10%. Prognosis is above all a function of the cause. Age, duration of GCSE symptoms and the speed and quality of management also affect prognosis. Current guidelines are based only very partially on data and evidence. Defining GCSE at its different stages is an essential prerequisite for the treatment trials that are necessary.