Management Plan for Status Epilepticus
The first-line treatment for status epilepticus is intravenous lorazepam 0.1 mg/kg (maximum 4 mg) given slowly over 2 minutes, which has a success rate of approximately 65% in terminating seizures. 1
Initial Management (0-5 minutes)
- Assess and secure airway, breathing, and circulation
- Provide high-flow oxygen
- Check blood glucose level and correct if abnormal
- Establish IV access
- Continuous vital sign monitoring
First-Line Treatment (5-10 minutes)
- Lorazepam (Ativan): 0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min 2
- If seizures cease, no additional lorazepam is required
- If seizures continue or recur after 10-15 minutes, administer a second dose of lorazepam 0.1 mg/kg IV
Second-Line Treatment (20-40 minutes)
If seizures persist after two doses of lorazepam, proceed to:
- Fosphenytoin (Cerebyx): 20 mg PE/kg IV at maximum rate of 150 mg PE/min 3 OR
- Phenytoin (Dilantin): 20 mg/kg IV at maximum rate of 50 mg/min 4 OR
- Valproate (Depacon): 20-30 mg/kg IV at rate of 40 mg/min 4 OR
- Levetiracetam (Keppra): 30-50 mg/kg IV at 100 mg/min 4, 1
Important considerations for second-line agents:
- Fosphenytoin is preferred over phenytoin due to fewer adverse effects and faster administration
- Phenytoin must be diluted in normal saline (NOT glucose solutions)
- Monitor heart rate during phenytoin/fosphenytoin infusion; reduce rate if heart rate decreases by 10 beats/min
- Valproate has fewer cardiovascular adverse effects than phenytoin
Refractory Status Epilepticus (>40 minutes)
If seizures continue after second-line treatment:
- Transfer to ICU if not already there
- Initiate continuous EEG monitoring
- Consider intubation for airway protection
Choose one of the following:
- Phenobarbital: 20 mg/kg IV at rate not exceeding 50-100 mg/min 4, 1 OR
- Midazolam: Loading dose 0.2 mg/kg IV, followed by continuous infusion starting at 0.1 mg/kg/hr, increasing by 0.05-0.1 mg/kg/hr every 15 minutes until seizures stop (maximum 2 mg/kg/hr) 4 OR
- Propofol: 2 mg/kg IV bolus, followed by continuous infusion at 5 mg/kg/hr, titrating to effect 4, 1
Super-Refractory Status Epilepticus (>24 hours)
If seizures persist despite above measures:
- Pentobarbital: 5-15 mg/kg IV loading dose, followed by continuous infusion at 0.5-5 mg/kg/hr 4
- Consider adjunctive therapy with:
- Ketamine: 1-2 mg/kg IV bolus followed by 1-5 mg/kg/hr infusion
- Magnesium sulfate: 4 g IV over 10 minutes (for suspected eclampsia)
Maintenance Therapy After Seizure Control
- Lorazepam: 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 4
- Levetiracetam: 30 mg/kg/day divided twice daily 4
- Phenytoin/Fosphenytoin: Maintenance dose of 4-7 mg/kg/day divided into 2-3 doses
- Valproate: 20-30 mg/kg/day divided twice daily
Special Considerations
Monitoring
- Continuous cardiac monitoring during and after treatment
- Frequent blood pressure checks
- Continuous pulse oximetry
- Consider arterial line for hemodynamic monitoring in refractory cases
Potential Complications and Management
- Respiratory depression: Have ventilation equipment immediately available; be prepared to intubate 2
- Hypotension: IV fluids; vasopressors if needed
- Cardiac arrhythmias: More common with phenytoin/fosphenytoin; monitor ECG
- Purple glove syndrome: Risk with phenytoin; use fosphenytoin when possible
Common Pitfalls to Avoid
- Underdosing benzodiazepines in the initial treatment
- Administering phenytoin too rapidly (>50 mg/min)
- Mixing phenytoin with glucose-containing solutions
- Failure to recognize and treat non-convulsive status epilepticus
- Delaying treatment while waiting for diagnostic studies
Non-IV Access Alternatives
If IV access cannot be established immediately:
- Midazolam: 0.2 mg/kg IM (maximum 10 mg) 4
- Diazepam: 0.5 mg/kg rectally (maximum 20 mg)
Remember that status epilepticus is a neurological emergency with significant morbidity and mortality. Prompt, aggressive treatment following this protocol significantly improves outcomes.