What is the management of status epilepticus?

Management of Status Epilepticus

Status epilepticus should be treated with benzodiazepines as first-line therapy, followed by levetiracetam, fosphenytoin, or valproate as equally effective second-line options if seizures persist. 1

Definition and Recognition

• Status epilepticus is defined as a seizure lasting longer than 5 minutes or multiple seizures without return to neurological baseline 1
• Represents a medical emergency requiring immediate intervention to prevent morbidity and mortality

Treatment Algorithm

Step 1: Initial Stabilization (0-5 minutes)

• Secure airway, breathing, and circulation
• Position patient on side in recovery position to prevent aspiration
• Obtain IV access
• Check blood glucose levels
• Monitor vital signs
• Clear area around patient to prevent injury 1

Step 2: First-Line Treatment (5-20 minutes)

• Benzodiazepines are first-line treatment
• Lorazepam 4 mg IV given slowly (2 mg/min) is the preferred agent 2, 1
• If seizures continue after 10-15 minutes, administer an additional 4 mg IV dose 2
• Alternative routes if IV access unavailable:
  • Midazolam: Intramuscular, intranasal, or buccal
  • Diazepam: Rectal 1

Step 3: Second-Line Treatment (20-40 minutes)

• If seizures persist despite benzodiazepines, administer one of the following:
  • Levetiracetam: 30-60 mg/kg IV
  • Fosphenytoin: 20 mg PE/kg IV
  • Valproate: 30 mg/kg IV 1, 3
• All three medications have similar efficacy (approximately 50% seizure cessation) 3, 1
• Medication selection considerations:
  • Levetiracetam: Preferred in hepatic dysfunction
  • Fosphenytoin: May cause hypotension
  • Valproate: Avoid in suspected hepatotoxicity 1

Step 4: Refractory Status Epilepticus (>40 minutes)

• Transfer to ICU with continuous EEG monitoring
• Consider anesthetic agents:
  • Midazolam: IV infusion
  • Propofol: IV infusion
  • Ketamine: IV infusion
  • Barbiturates (phenobarbital, pentobarbital) 3, 1, 4

Diagnostic Evaluation

• Essential laboratory tests:

  • Serum glucose
  • Serum sodium
  • Complete metabolic panel
  • Toxicology screen (if indicated)
  • CBC, blood cultures (if fever present)
  • Antiepileptic drug levels (in patients on seizure medications)
  • CK levels (after generalized tonic-clonic seizure) 1

• Neuroimaging:

  • Brain CT or MRI to identify structural causes
  • MRI preferred for new-onset seizures in non-emergent setting 1

• EEG:

  • Continuous EEG monitoring for refractory cases
  • Essential for detecting non-convulsive seizures 1

Common Pitfalls to Avoid

1. Inadequate benzodiazepine dosing: Ensure full recommended doses are given
2. Delayed treatment: Time is brain - initiate treatment promptly
3. Failure to monitor respiratory status: Benzodiazepines may cause respiratory depression
4. Missing non-convulsive status: Consider EEG monitoring
5. Overlooking treatable causes: Hypoglycemia, hyponatremia, drug toxicity, infection 1, 2

Special Considerations

• Pregnancy: Levetiracetam or valproate preferred over phenytoin
• Hepatic dysfunction: Avoid valproate, consider levetiracetam
• Alcohol withdrawal: Phenytoin may be less effective 3
• Elderly patients: May require dose adjustments, monitor closely for adverse effects 2

Disposition

• Patients with controlled seizures who return to baseline may be discharged with:

  • Seizure precautions and safety measures
  • Driving restrictions per local laws
  • Medication instructions
  • Neurology follow-up 1

• Admission criteria:

  • First-time seizure requiring further evaluation
  • Status epilepticus
  • Abnormal neuroimaging
  • Persistent altered mental status
  • No reliable follow-up 1

The ESETT trial demonstrated that levetiracetam, fosphenytoin, and valproate are equally effective as second-line agents, with each achieving seizure cessation in approximately half of patients 3, 1. Early and aggressive treatment is essential to reduce the morbidity and mortality associated with status epilepticus.