Step-wise Management of Status Epilepticus
The management of status epilepticus requires immediate intervention following a structured protocol, with benzodiazepines as first-line treatment followed by antiseizure medications and, if necessary, anesthetic agents for refractory cases. 1
Initial Assessment and Stabilization (0-5 minutes)
- Assess circulation, airway, and breathing (CAB)
- Position patient on their side (recovery position)
- Clear area of hazardous objects
- Provide airway protection interventions
- Administer high-flow oxygen
- Check blood glucose level
- Establish IV access
- Monitor vital signs
First-Line Treatment (5-20 minutes)
For Convulsive Status Epilepticus:
- Lorazepam 0.1 mg/kg IV (maximum 4 mg) 1
- May repeat once after 5 minutes if seizures persist
- Maximum of 2 doses
- Monitor for respiratory depression, especially when combined with other CNS depressants 2
For Non-convulsive Status Epilepticus:
- Lorazepam 0.05 mg/kg IV (maximum 1 mg) 3
- May repeat every 5 minutes up to 4 doses to control electrographical seizures
Second-Line Treatment (20-40 minutes)
If seizures persist after adequate benzodiazepine administration:
- Levetiracetam 40 mg/kg IV (maximum 2,500 mg) as a bolus 3, 1
- Preferred for young females, patients with renal or hepatic impairment, and those on multiple medications due to minimal drug interactions and favorable side effect profile
OR
- Valproate 20-30 mg/kg IV (88% efficacy rate)
- Avoid in young females due to teratogenicity risk 1
OR
- Phenytoin/Fosphenytoin 18-20 mg/kg IV (56% efficacy rate)
- Monitor for hypotension, cardiac dysrhythmias, and purple glove syndrome 1
Third-Line Treatment (40-60 minutes)
If seizures continue after second-line therapy:
- Transfer to intensive care unit (ICU)
- Add Phenobarbital 10-20 mg/kg IV (maximum 1,000 mg) 3, 4
- Initiate continuous EEG monitoring
- Consider corticosteroids if indicated (particularly for autoimmune causes) 3
Refractory Status Epilepticus (>60 minutes)
If seizures persist despite above measures:
- Midazolam continuous infusion (loading dose 0.2 mg/kg, followed by 0.1-0.4 mg/kg/hour) 4
OR
- Propofol continuous infusion (loading dose 1-2 mg/kg, followed by 2-10 mg/kg/hour) 4
Super-Refractory Status Epilepticus (>24 hours)
If seizures continue or recur 24 hours after anesthetic therapy:
- Ketamine infusion
- Barbiturates (pentobarbital or thiopental)
- Consider additional non-sedating antiseizure medications
- Evaluate for underlying causes requiring specific treatment (particularly autoimmune encephalitis) 4
Maintenance Therapy After Resolution
- Lorazepam 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 3
- Levetiracetam 15-30 mg/kg IV every 12 hours 3
- Phenobarbital 1-3 mg/kg IV every 12 hours if used during acute management 3
Monitoring
- Continuous EEG monitoring for refractory and super-refractory cases
- Regular vital sign monitoring
- Assess for respiratory depression, especially with benzodiazepines and barbiturates
- Monitor for hypotension with phenytoin/fosphenytoin and anesthetic agents
- Evaluate for drug-specific adverse effects
Prognosis and Outcomes
Status epilepticus carries significant mortality risk, ranging from 5-22% overall 3. Mortality increases with:
- Increasing age
- Underlying etiology (particularly CNS infections)
- Medical comorbidities
- Treatment refractoriness (10% mortality in responsive cases, 25% in refractory, and nearly 40% in super-refractory SE) 4
Important Considerations
- Time is critical - delays in treatment increase mortality and neurological sequelae
- Adequate dosing of first-line agents is essential for successful seizure termination
- Always investigate and treat underlying causes (metabolic derangements, infections, stroke, trauma)
- Institutional protocols improve outcomes by standardizing care and reducing treatment delays 5
- Continuous EEG monitoring is essential for non-convulsive status epilepticus and after control of convulsive status epilepticus 5