From the Guidelines
For a rapid response to status epilepticus, administer intravenous lorazepam 0.1 mg/kg (maximum 2 mg) as first-line treatment, which can be repeated after at least 1 minute (to a maximum of 2 doses) to control seizures. This approach is supported by the most recent and highest quality study 1, which emphasizes the importance of early treatment in reducing morbidity and mortality. The initial management should also include assessing the patient's airway, breathing, and circulation (CAB), providing airway protection interventions, administering high-flow oxygen, and checking blood glucose level 1.
Key steps in managing status epilepticus include:
- Administering lorazepam 0.1 mg/kg (maximum 2 mg) i.v.; repeat dose after at least 1 minute (to a maximum of 2 doses) to control seizures
- Giving levetiracetam 40 mg/kg (maximum 2,500 mg) i.v. bolus (in addition to maintenance dose) if seizures persist
- Adding phenobarbital i.v. at a loading dose of 10–20 mg/kg (maximum 1,000 mg) if seizures continue
- Maintaining doses after resolution of status epilepticus, such as lorazepam 0.05 mg/kg (maximum 1 mg) i.v. every 8 hours for 3 doses, levetiracetam 30 mg/kg i.v. every 12 hours, and phenobarbital 1–3 mg/kg i.v. every 12 hours 1
It is crucial to prioritize the patient's airway, breathing, and circulation, and to continuously monitor their vital signs. The use of benzodiazepines, such as lorazepam, as first-line treatment is supported by the evidence, and the addition of second-line agents like levetiracetam, fosphenytoin, or valproate may be necessary if seizures persist 1. Rapid intervention is essential to prevent neuronal damage and reduce the risk of morbidity and mortality associated with status epilepticus.
From the FDA Drug Label
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. 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 appropriate response to a status epilepticus (seizure) includes:
- Administration of lorazepam injection: 4 mg given slowly (2 mg/min) for patients 18 years and older
- Observation and management: of all parameters critical to maintaining vital function
- Support of vital functions: as required
- Monitoring for recurrence: if seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered 2
From the Research
Appropriate Response to Status Epilepticus
The appropriate response to status epilepticus involves the timely administration of antiepileptic drugs (AEDs) to stop seizures early and improve outcomes 3.
First-Line Treatment
- The established first-line treatment for status epilepticus consists of benzodiazepines, most frequently intravenous lorazepam 3.
- Other benzodiazepines like intranasal midazolam or intramuscular midazolam are also effective and becoming more popular due to easier administration in the field 3.
Second-Line Treatment
- After treatment with benzodiazepines, treatment with fosphenytoin and phenobarbital is usually recommended 3.
- Other intravenously available AEDs like valproate and levetiracetam may be as effective and safe as fosphenytoin and phenobarbital, with a faster infusion time and better pharmacokinetic profile 3.
- Levetiracetam has been shown to be non-inferior to fosphenytoin as a second-line treatment for adult convulsive status epilepticus 4.
- Levetiracetam may be preferred over fosphenytoin due to its similar efficacy and higher safety profile, particularly in patients with respiratory compromise and hypotension 5, 6, 7.