What medications are used to treat status epilepticus in the Intensive Care Unit (ICU)?

Medications for Status Epilepticus in the ICU

The treatment of status epilepticus in the ICU should follow a stepwise approach with benzodiazepines as first-line therapy, followed by antiepileptic drugs, and then anesthetic agents for refractory cases. 1

First-Line Treatment

• Lorazepam is the drug of choice for initial treatment:

  • Adult dose: 4 mg IV (0.1 mg/kg up to 2 mg for convulsive status) 1, 2
  • Can repeat after 10-15 minutes if seizures continue 2
  • Success rate approximately 65% 1
  • Advantages: Longer duration of action than diazepam 3

• If IV access is unavailable, consider:

  • Midazolam 0.2 mg/kg IM 1
  • Rectal diazepam or buccal/nasal midazolam 4

Second-Line Treatment (if seizures persist after benzodiazepines)

Choose one of the following:

• Levetiracetam: 30-50 mg/kg IV (up to 2500 mg) 5, 1

  • Success rate: 44-73% 1
  • Minimal adverse effects and drug interactions 1

• Valproate: 20-30 mg/kg IV 1

  • Success rate: 88% 1
  • Generally preferred due to efficacy with minimal drug interactions 1

• Fosphenytoin/Phenytoin: 18-20 mg/kg IV at maximum rate of 150 PE/min 1

  • Success rate: 56% 1
  • Caution: Can cause hypotension, cardiac dysrhythmias, purple glove syndrome 1

• Phenobarbital: 10-20 mg/kg IV (maximum 1000 mg) 5, 1

  • Success rate: 58% 1
  • Caution: Can cause respiratory depression and hypotension 1

Third-Line Treatment (Refractory Status Epilepticus)

If seizures continue after first and second-line treatments:

• Propofol: 2 mg/kg bolus, followed by 5 mg/kg/h infusion 1

  • Caution: Can cause hypotension 1

• Midazolam: Continuous IV infusion at 4-30 mg/hour 6

  • Often preferred initial anesthetic agent 3

• Pentobarbital: Continuous infusion 1

  • Success rate: 92% 1
  • Significant hypotension is common 1

• Ketamine: Consider for cases refractory to other anesthetics 1

  • Advantage: Has sympathomimetic effects that may mitigate hemodynamic instability 1

Monitoring and Supportive Care

• Maintain patent airway and provide respiratory support as needed 5, 2
• Continuous EEG monitoring for refractory cases and to confirm seizure cessation 5, 3
• Monitor vital signs and provide cardiovascular support if needed 6
• Check blood glucose and correct if abnormal 5

Special Considerations

• For non-convulsive status epilepticus:

  • Initial approach similar to convulsive status 3
  • EEG monitoring is crucial for diagnosis and treatment assessment 3
  • Balance aggressiveness of treatment against risk of complications 3

• After seizure control:

  • Transition to maintenance therapy:
    • Lorazepam: 0.05 mg/kg (max 1 mg) IV every 8 hours for 3 doses 5
    • Levetiracetam: 15-30 mg/kg IV every 12 hours 5
    • Phenobarbital: 1-3 mg/kg IV every 12 hours 5

Common Pitfalls to Avoid

• Delay in treatment: Status epilepticus is a neurological emergency requiring immediate intervention 3, 7
• Inadequate dosing: Use full recommended doses of medications 4
• Failure to identify underlying causes: Correct metabolic abnormalities, toxins, or other treatable causes 2, 3
• Not recognizing non-convulsive status: Obtain EEG in patients with unexplained altered mental status 4
• Insufficient monitoring: Continuous EEG is necessary when using anesthetic agents, especially if neuromuscular blockade is required 6

Remember that status epilepticus management requires a protocolized approach with rapid escalation of therapy if initial treatments fail. Time is brain - prompt and aggressive treatment is essential to prevent neurological damage.