From the Guidelines
Status epilepticus should be managed with urgent control of seizures using benzodiazepines as first-line therapy, followed by second-line agents such as levetiracetam, fosphenytoin, or valproate, with the goal of reducing morbidity and mortality. The diagnosis of status epilepticus involves identifying prolonged seizures lasting more than 5 minutes or multiple seizures without recovery of consciousness between them. Initial management involves stabilizing the patient by securing the airway, ensuring adequate breathing, and maintaining circulation.
First-line Treatment
First-line medication treatment is intravenous benzodiazepines, specifically lorazepam 4 mg IV (or diazepam 10 mg IV if lorazepam is unavailable), which can be repeated once after 5-10 minutes if seizures continue 1.
Second-line Treatment
If seizures persist, second-line therapy includes fosphenytoin (20 mg PE/kg IV at 150 mg/min), valproic acid (40 mg/kg IV over 10 minutes), or levetiracetam (60 mg/kg IV over 15 minutes) 1.
Refractory Status Epilepticus
For refractory status epilepticus, continuous infusions of midazolam, propofol, or pentobarbital may be necessary under ICU monitoring with EEG guidance.
Underlying Cause
Identifying and treating the underlying cause is crucial, which may include metabolic abnormalities, infection, stroke, trauma, or medication withdrawal.
Importance of Prompt Treatment
Prompt treatment is essential as prolonged seizures can cause neuronal damage, with mortality increasing significantly after 30 minutes of continuous seizure activity due to excitotoxicity from excessive glutamate release and subsequent neuronal death. According to the most recent study 1, the use of levetiracetam, fosphenytoin, or valproate will result in cessation of seizures in approximately half of all patients, with the benefit of early treatment and cessation of status epilepticus being a reduction in morbidity and mortality.
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
The diagnosis of status epilepticus involves identifying a potentially life-threatening condition with a high risk of permanent neurological impairment if inadequately treated. The management of status epilepticus requires:
- Observation and management of vital functions
- Ventilatory support
- Initial treatment with benzodiazepines like lorazepam, followed by possible additional interventions (e.g., phenytoin)
- Identification and correction of underlying causes (e.g., hypoglycemia, hyponatremia)
- Maintenance antiepileptic therapy for patients susceptible to further seizures Key considerations include:
- Intravenous administration of lorazepam (4 mg given slowly for patients 18 years and older)
- Monitoring of vital signs and maintenance of an unobstructed airway
- Availability of artificial ventilation equipment 2
From the Research
Diagnosis of Status Epilepticus
- Status epilepticus (SE) is a medical emergency that requires prompt diagnosis and treatment, as delay is associated with a higher likelihood of poor response to treatment and worse outcome 3.
- The present operational definition for adults and older children considers status as > or = 5 minutes of continuous seizure or two or more discrete seizures without regaining of full consciousness 4.
- An electroencephalogram (EEG) should be obtained immediately in anyone with unexplained alteration of behavior or mental status and after convulsive SE if the patient does not rapidly awaken 5, 3.
- Nonconvulsive SE is underdiagnosed and may cause primary cerebral injury due to prolonged uncontrolled neuronal discharge or secondary cerebral injury due to hypoxia and hypothermia 6.
Management of Status Epilepticus
- Lorazepam is the drug of choice for initial treatment of SE, and if intravenous access is not immediately available, then rectal diazepam or nasal or buccal midazolam should be given 5, 3.
- Benzodiazepine is considered the 1st line of treatment outside the hospital, and emergency/inpatient management includes basic life support and pharmacological management 4.
- Drugs used in pharmacological management include lorazepam, midazolam, propofol, phenobarbital, phenytoin, fosphenytoin, i.v. valproate, and rectal diazepam 4, 6, 3.
- For refractory SE, continuous intravenous midazolam and propofol, separately or in combination, are rapidly effective, with pentobarbital remaining the gold standard for prolonged cases 5, 3.
Refractory Status Epilepticus
- The classical definition of refractory status epilepticus includes seizure that has not responded to sequential treatment of lorazepam, phenytoin, or phenobarbitone or seizure continuing > 60-90 minutes in spite of adequate treatment 4.
- Refractory SE requires continuous EEG monitoring to recognize recurrence of seizure activity, as most seizures will be nonconvulsive 3.
- Diazepam (or midazolam), thiopental, and propofol infusion are useful for control of Refractory SE (RSE) 7.