What is the algorithm for managing Status Epilepticus?

From the Guidelines

The management of status epilepticus should follow a stepwise approach, starting with stabilization and first-line therapy using benzodiazepines, followed by second-line therapy with IV fosphenytoin, valproate, or levetiracetam, and finally, third-line therapy with midazolam, propofol, or pentobarbital for refractory cases, as recommended by the most recent guidelines 1.

Step 1: Stabilization and First-Line Therapy

• Ensure airway, breathing, and circulation
• Administer benzodiazepines as first-line treatment:
  • IV lorazepam (0.1 mg/kg, max 4 mg)
  • IV diazepam (0.15-0.2 mg/kg, max 10 mg)
  • IM midazolam (10 mg for >40 kg; 5 mg for 13-40 kg)
  • Rectal diazepam (0.2-0.5 mg/kg)

Step 2: Second-Line Therapy

• If seizures persist after 5-10 minutes, proceed to second-line therapy:
  • IV fosphenytoin (20 mg PE/kg at 150 mg/min)
  • IV valproate (40 mg/kg over 10 minutes)
  • IV levetiracetam (60 mg/kg, max 4500 mg over 10 minutes)
• These agents have been shown to be effective in terminating seizures in approximately half of all patients with benzodiazepine-resistant status epilepticus 1

Step 3: Third-Line Therapy for Refractory Status Epilepticus

• For refractory status epilepticus, initiate continuous EEG monitoring and administer:
  • Midazolam (loading dose 0.2 mg/kg, then 0.1-2 mg/kg/hr)
  • Propofol (1-2 mg/kg load, then 2-10 mg/kg/hr)
  • Pentobarbital (5-15 mg/kg load, then 0.5-5 mg/kg/hr)
• IV valproate has been advocated as an alternative to phenytoin and even as first-line therapy for status epilepticus, with potentially fewer adverse effects 1

Additional Considerations

• Address underlying causes such as metabolic abnormalities, infection, trauma, or medication withdrawal
• Monitor vital signs, oxygen saturation, and blood glucose levels
• Consider thiamine 100 mg IV and glucose 50 mL of D50W if hypoglycemia is suspected
• The benefit of early treatment and cessation of status epilepticus is a reduction in morbidity and mortality, with limited harms 1

From the FDA Drug Label

Status Epilepticus General Advice Status epilepticus is a potentially life-threatening condition associated with a high risk of permanent neurological impairment, if inadequately treated The treatment of status, however, requires far more than the administration of an anticonvulsant agent. It involves observation and management of all parameters critical to maintaining vital function and the capacity to provide support of those functions as required. Ventilatory support must be readily available The use of benzodiazepines, like lorazepam injection, is ordinarily only an initial step of a complex and sustained intervention which may require additional interventions (e.g., concomitant intravenous administration of phenytoin). Because status epilepticus may result from a correctable acute cause such as hypoglycemia, hyponatremia, or other metabolic or toxic derangement, such an abnormality must be immediately sought and corrected. Furthermore, patients who are susceptible to further seizure episodes should receive adequate maintenance antiepileptic therapy Any health care professional who intends to treat a patient with status epilepticus should be familiar with this package insert and the pertinent medical literature concerning current concepts for the treatment of status epilepticus. A comprehensive review of the considerations critical to the informed and prudent management of status epilepticus cannot be provided in drug product labeling The archival medical literature contains many informative references on the management of status epilepticus, among them the report of the working group on status epilepticus of the Epilepsy Foundation of America “Treatment of Convulsive Status Epilepticus” (JAMA 1993; 270:854-859). As noted in the report just cited, it may be useful to consult with a neurologist if a patient fails to respond (e.g., fails to regain consciousness). Intravenous Injection For the treatment of status epilepticus, the usual recommended dose of lorazepam injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional lorazepam injection is required If seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered.

The algorithm for status epilepticus involves:

• Initial Assessment: Identify and correct any underlying cause of status epilepticus, such as hypoglycemia or hyponatremia.
• Initial Treatment: Administer lorazepam 4 mg IV slowly (2 mg/min) for patients 18 years and older.
• Monitoring: Observe the patient for 10-15 minutes after the initial dose.
• Additional Treatment: If seizures continue or recur, administer an additional 4 mg IV dose of lorazepam.
• Supportive Care: Ensure ventilatory support is readily available and maintain an unobstructed airway.
• Consultation: Consider consulting a neurologist if the patient fails to respond to treatment 2.

From the Research

Status Epilepticus Algorithm

The following algorithm is based on the provided evidence:

• Initial Stabilization: Stabilize airway, breathing, and circulation 3
• Seizure Termination:
  • First-line treatment: Benzodiazepines (lorazepam, diazepam, or midazolam) 4, 5, 6, 7
  • Second-line treatment: Phenytoin, fosphenytoin, valproate, or levetiracetam 4, 5, 6, 7
• Refractory Status Epilepticus:
  • Midazolam infusion, propofol, or pentobarbital 4, 5, 3
  • Consider adding a second IV nonsedating antiseizure medication or starting an anesthetizing continuous IV infusion antiseizure medication 7
• Evaluation and Treatment of Underlying Cause:
  • Diagnostic evaluation and seizure control should be achieved simultaneously to improve outcome 4
  • Attend to the general condition of the patient and ensure hemodynamic stability 6
• Monitoring:
  • Continuous EEG monitoring for refractory status epilepticus to recognize recurrence of seizure activity 5
  • Urgent EEG to rule out nonconvulsive seizure activity if the patient does not awaken after treatment 5