From the Guidelines
Status epilepticus treatment requires immediate intervention with a stepwise approach, prioritizing benzodiazepines as first-line treatment, followed by second-line therapy with fosphenytoin, valproate, or levetiracetam, and third-line treatment with continuous infusions of midazolam, propofol, or pentobarbital for refractory cases, as supported by the most recent evidence from 1.
Stepwise Approach to Status Epilepticus Treatment
The treatment approach involves:
- First-line treatment with benzodiazepines: intravenous lorazepam (0.1 mg/kg, max 4 mg) or diazepam (0.15-0.2 mg/kg, max 10 mg), or intramuscular midazolam (10 mg for adults >40 kg) 1.
- Second-line therapy with fosphenytoin (20 mg PE/kg IV at 150 mg/min), valproate (40 mg/kg IV over 10 minutes), or levetiracetam (60 mg/kg IV over 15 minutes, max 4500 mg) if seizures persist after 5-10 minutes 1.
- Third-line treatment involves continuous infusions of midazolam (loading 0.2 mg/kg, maintenance 0.1-2 mg/kg/hr), propofol (1-2 mg/kg loading, 2-10 mg/kg/hr maintenance), or pentobarbital (5-15 mg/kg loading, 0.5-10 mg/kg/hr maintenance) with EEG monitoring for refractory status epilepticus 1.
Key Considerations
- Maintain airway protection, provide oxygen, establish IV access, check glucose levels, and obtain labs including toxicology screen throughout treatment 1.
- Identify and treat underlying causes such as infection, stroke, trauma, or medication withdrawal 1.
- Continuous EEG monitoring is essential for refractory cases to guide therapy and detect subclinical seizures 1.
- The benefit of early treatment and cessation of status epilepticus is a reduction in morbidity and mortality, with limited harms apart from potential adverse drug reactions 1.
From the FDA Drug Label
The treatment of status, however, requires far more than the administration of an anticonvulsant agent. It involves observation and management of all parameters critical to maintaining vital function and the capacity to provide support of those functions as required. The use of benzodiazepines, like lorazepam injection, is ordinarily only an initial step of a complex and sustained intervention which may require additional interventions (e.g., concomitant intravenous administration of phenytoin). For the treatment of status epilepticus, the usual recommended dose of lorazepam injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional lorazepam injection is required If seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered.
The treatment for status epilepticus involves:
- Observation and management of vital functions
- Initial administration of benzodiazepines like lorazepam
- Possible additional interventions, such as concomitant intravenous administration of phenytoin
- For patients 18 years and older, the recommended initial dose of lorazepam is 4 mg given slowly, with a possible additional dose of 4 mg after a 10- to 15-minute observation period if seizures continue or recur 2
From the Research
Treatment Overview
The treatment for status epilepticus involves several stages, including initial stabilization, seizure termination, and evaluation and treatment of the underlying cause 3, 4.
First-Line Treatment
- Benzodiazepines, such as diazepam, midazolam, or lorazepam, are considered the first-line therapy for status epilepticus 3, 5, 4, 6.
- These medications can be administered intravenously, and in some cases, buccal or nasal midazolam or rectal diazepam can be used in children without IV access 4.
Second-Line Treatment
- Phenytoin, valproic acid, levetiracetam, and phenobarbital are commonly used as second-line agents for status epilepticus 7, 5, 4, 6.
- These medications are usually indicated when seizure is not controlled after one or more doses of benzodiazepines 4.
Refractory Status Epilepticus
- Refractory status epilepticus requires the use of anesthetic agents, such as midazolam, propofol, pentobarbital, or ketamine, with monitoring of treatment effect by continuous EEG 5, 6.
- Thiopentone, propofol, or high-dose phenobarbitone are also considered for treatment of refractory status epilepticus 4.