Management of Status Epilepticus
The first-line treatment for status epilepticus is intravenous lorazepam 0.1 mg/kg (maximum 4 mg), which has a success rate of approximately 65%. 1
Treatment Algorithm
Initial Management (0-5 minutes)
- Ensure patent airway, adequate oxygenation, and circulatory support
- Position patient on side (recovery position)
- Monitor vital signs
- Establish IV access
- Check glucose levels and correct if hypoglycemic
- Consider other reversible causes (electrolyte abnormalities, toxins)
First-Line Therapy (5-20 minutes)
- Administer lorazepam 0.1 mg/kg IV (maximum 4 mg) at 2 mg/min 1, 2
- Equipment for airway management must be immediately available due to risk of respiratory depression 2
Second-Line Therapy (20-40 minutes)
If seizures continue after 10-15 minutes:
- Additional lorazepam 4 mg IV may be administered 2
- OR valproate 20-30 mg/kg IV (88% success rate) 1
- OR levetiracetam 40 mg/kg IV (maximum 2,500 mg) (44-73% success rate) 1
- OR phenytoin/fosphenytoin 18-20 mg/kg IV (56% success rate) 1
Third-Line Therapy (Refractory Status Epilepticus)
If seizures continue after second-line therapy:
- Phenobarbital 10-20 mg/kg IV (58% success rate) 1
- Consider anesthetic agents:
Medication Comparison
| Medication | Dose | Success Rate | Adverse Effects |
|---|---|---|---|
| Lorazepam | 0.1 mg/kg IV (max 4 mg) | 65% | Respiratory depression |
| Valproate | 20-30 mg/kg IV | 88% | GI disturbances, somnolence, tremor |
| Levetiracetam | 30-50 mg/kg IV | 44-73% | Minimal |
| Phenytoin | 18-20 mg/kg IV | 56% | Hypotension, cardiac dysrhythmias, purple glove syndrome |
| Phenobarbital | 10-20 mg/kg IV | 58% | Respiratory depression, hypotension |
Special Considerations
Monitoring
- Continuous EEG monitoring is essential for refractory cases 1
- Monitor vital signs, especially respiratory status and blood pressure
- Regular neurocognitive assessment is important, particularly in pediatric cases 1
Pediatric Management
- Lorazepam remains first-line therapy at the same dose as adults
- Levetiracetam is recommended for pediatric patients due to favorable safety profile 1
- Use valproate with caution in females of childbearing potential and children under 2 years due to risk of hepatotoxicity 1
Subtle Status Epilepticus
- More difficult to treat than overt convulsive status epilepticus
- Success rates for all medications are lower (7.7-24.2%) 3
- Requires EEG monitoring for diagnosis and treatment assessment
Common Pitfalls and Caveats
Delayed Treatment: Status epilepticus is a neurologic emergency requiring immediate treatment. Each minute of delay increases the risk of neuronal injury and reduces the likelihood of successful termination with first-line agents 4.
Inadequate Dosing: Underdosing of anticonvulsants is common. Follow recommended dosing guidelines closely 1, 2.
Failure to Recognize Subtle Status Epilepticus: Not all status epilepticus presents with obvious convulsions. Patients may have subtle motor manifestations or purely electrographic seizures requiring EEG for diagnosis 3, 4.
Neglecting Underlying Causes: Always search for and treat the underlying cause (hypoglycemia, hyponatremia, toxins, infection, etc.) 2, 5.
Inadequate Respiratory Monitoring: Benzodiazepines and barbiturates can cause respiratory depression. Always have airway equipment immediately available 2.
Failure to Escalate Therapy: If first-line treatment fails, promptly move to second-line agents. Refractory status epilepticus requires aggressive management 1, 6.
Overlooking Drug Interactions: Many anticonvulsants interact with other medications. Be aware of potential interactions when selecting agents 2.
A comparative study between levetiracetam and lorazepam showed that both were equally effective in controlling status epilepticus (76.3% vs 75.6%), but lorazepam was associated with significantly higher need for artificial ventilation 7. However, the most recent guidelines still recommend lorazepam as first-line therapy due to its established efficacy 1.