Champ 7 - prise en charge de l'état de mal tonicoclonique généralisé : stratégies thérapeutiques

The prolongation of generalized tonic-clonic status epilepticus increases the risk of neuronal damage and systemic complications. It is also a recognised contributing factor to drug-resistance. Thus, the expected quality of anticonvulsive drug to choose in this situation is its rapid therapeutic effect, without resulting in severe neurological, cardiovascular or respiratory side-effects. The anticonvulsive strategy proposed here takes into account these necessities as well as published data which remain limited on many aspects, however. For the initial treatment, it is necessary to take into account the seizure duration until medical intervention. If less than 30 min, a monotherapy with benzodiazepine seems necessary and initially sufficient. In the absence of lorazepam, which is unavailable in France, clonazepam is the alternative choice since possessing similar pharmacokinetics. Beyond 30 min, a combination of benzodiazepine and long-lasting anticonvulsive drug - phenobarbital or fosphenytoin - is indicated. The choice between both drugs depends on their respective contra-indications and the medical history of the status epilepticus. The persistence of seizures beyond 20 min after beginning phenobarbital infusion or 30 min after fosphenytoin infusion corresponds to a failure of the initial treatment and requires an immediate second-line therapy. This may be a long-lasting anticonvulsive drug, providing seizures have been present for less than one hour, with no suspicion of acute cerebral injury or any associated systemic factor of cerebral aggression. If not, anaesthetic drugs are immediately required.