From the Guidelines
Status epilepticus requires immediate treatment following UK guidelines, starting with intravenous lorazepam 4mg (or 0.1mg/kg) given over 2-4 minutes, which can be repeated once after 10 minutes if seizures continue, as recommended by recent guidelines 1.
Initial Management
To manage status epilepticus, first secure the airway, breathing, and circulation while administering high-flow oxygen.
- If IV access is available, use intravenous lorazepam 4mg (or 0.1mg/kg) given over 2-4 minutes; this can be repeated once after 10 minutes if seizures continue.
- If IV access isn't available, use midazolam 10mg buccally or intramuscularly.
Second-Line Therapy
If seizures persist after 20 minutes, move to second-line therapy with:
- Phenytoin 20mg/kg IV at a rate not exceeding 50mg/minute,
- Or valproate 40mg/kg IV over 5-10 minutes (maximum 3g), as valproate has been shown to be at least as effective as phenytoin for refractory status epilepticus, with potentially fewer adverse effects 1.
Refractory Status Epilepticus
For refractory status epilepticus (continuing beyond 30-60 minutes), transfer to intensive care for general anesthesia with propofol, midazolam, or thiopental infusions. Throughout treatment, monitor vital signs, oxygen saturation, ECG, and blood glucose. Correct any underlying causes such as hypoglycemia (treat with 50ml of 50% glucose), electrolyte disturbances, or infection. Benzodiazepines work by enhancing GABA inhibitory effects in the brain, while phenytoin and valproate stabilize neuronal membranes by blocking sodium channels, preventing the spread of abnormal electrical activity.
From the FDA Drug Label
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 In adults, a loading dose of 10 to 15 mg/kg should be administered slowly intravenously, at a rate not exceeding 50 mg per minute The pediatric population, a loading dose of 15 to 20 mg/kg of phenytoin sodium intravenously will usually produce serum concentrations of phenytoin within the generally accepted serum total concentrations between 10 and 20 mcg/mL
Status Epilepticus Treatment:
- Lorazepam: 4 mg IV, given slowly (2 mg/min) for patients 18 years and older 2
- Phenytoin:
From the Research
Status Epilepticus Management
Status epilepticus is a medical emergency that requires urgent termination of seizures and management of the initiating factors. The treatment approach varies based on the time and the treatment stage of status epilepticus.
First-Line Treatment
- Benzodiazepines are considered the first-line therapy during the emergent treatment phase of status epilepticus 4, 5, 6, 7.
- Intravenous lorazepam (2-8 mg/70kg) or diazepam (5-20 mg/70kg) are recommended as 'first-line' therapy 4.
- Phenytoin (1500 - 2000 mg/70 kg) is also used as a first-line treatment, which will control seizures in up to 70% of patients 4.
Second-Line Treatment
- If status epilepticus becomes resistant to the initial treatment, 'second-line' drugs include:
- Intravenous phenobarbitone (100 -1000 mg) 4.
- Magnesium sulphate (10 - 15 mmol) 4.
- Midazolam (8-20 mg followed by an infusion at 4-30 mg/hour) 4, 5, 6.
- Propofol (50 - 150 mg followed by an infusion at 100 -500 mg/hour) 4, 6.
- Thiopentone (200 - 500 mg followed by an infusion at 100 - 500 mg/hr) 4.
- Lignocaine (100 -150 mg followed by an infusion of 150-200 mg/h) 4.
- Ketamine (50 - 100 mg followed by 50 - 100 mg/h) 4, 6.
- Isoflurane (0.5 - 1.5%) 4.