What is the standard treatment for status epilepticus?

Standard Treatment for Status Epilepticus

The standard treatment for status epilepticus begins with intravenous lorazepam 0.1 mg/kg (maximum 4 mg) administered slowly (2 mg/min), which has a success rate of approximately 65%, followed by second-line agents if seizures persist. 1, 2

Initial Management (0-5 minutes)

• Ensure patent airway, adequate oxygenation, and circulatory support
• Establish IV access immediately
• Check glucose levels and correct hypoglycemia if present
• Consider other correctable metabolic causes (hyponatremia, hypocalcemia)

First-Line Treatment (5-20 minutes)

• Benzodiazepines:
  • Lorazepam 0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min 1, 2
  • May repeat 0.05 mg/kg IV (maximum 1 mg) every 5 minutes to a maximum of 4 doses if needed 1
  • If IV access is unavailable, alternatives include rectal diazepam or nasal/buccal midazolam 3

Second-Line Treatment (20-40 minutes)

If seizures continue after benzodiazepine administration, proceed with one of the following:

• Valproate: 20-30 mg/kg IV (88% success rate) 4, 1
• Levetiracetam: 30-50 mg/kg IV (maximum 2,500 mg) (44-73% success rate) 1
• Phenytoin/Fosphenytoin: 18-20 mg/kg IV (56% success rate) 1
  • Administer at maximum rate of 50 mg/min
  • Monitor for hypotension, cardiac dysrhythmias, and purple glove syndrome
• Phenobarbital: 10-20 mg/kg IV (58% success rate) 1
  • Monitor for respiratory depression and hypotension

Refractory Status Epilepticus (>40 minutes)

If seizures persist after first and second-line treatments:

• Initiate continuous EEG monitoring 1
• Anesthetic agents:
  • Propofol: 2 mg/kg bolus, followed by 5-10 mg/kg/h infusion 1
  • Midazolam: 0.2 mg/kg bolus, followed by 0.1-0.4 mg/kg/h infusion
  • Pentobarbital: 5 mg/kg bolus, followed by 1-5 mg/kg/h infusion 4

Super-Refractory Status Epilepticus (>24 hours)

• Consider ketamine for early phase 3 status epilepticus 1
• IVIG may be considered (2 g/kg divided over 2-5 days) 1

Important Considerations

• Time is brain—delays in treatment increase morbidity and mortality 5
• Equipment to maintain a patent airway must be immediately available prior to IV administration of benzodiazepines 2
• Nonconvulsive status epilepticus should be considered in patients with altered mental status; EEG is essential for diagnosis 3, 5
• Prehospital treatment by emergency personnel is effective and safe, potentially preventing refractory cases 6

Treatment Efficacy Comparison

In overt generalized convulsive status epilepticus, success rates vary by medication:

• Lorazepam: 64.9%
• Phenobarbital: 58.2%
• Diazepam plus phenytoin: 55.8%
• Phenytoin alone: 43.6% 7

The treatment algorithm should be followed systematically and rapidly, with full medication doses as outlined above, to maximize the chances of seizure termination and minimize neurological sequelae.