Status Epilepticus Management Protocol
Status epilepticus should be treated immediately with IV lorazepam 0.05 mg/kg (maximum 4 mg) given slowly (2 mg/min) as first-line therapy, followed by additional antiseizure medications if seizures persist after 10-15 minutes. 1, 2
Definition and Initial Assessment
- Status epilepticus: Continuous seizure lasting >5 minutes or multiple seizures without return to baseline consciousness
- Immediate priorities:
- Ensure patent airway and adequate ventilation
- Establish IV access
- Monitor vital signs
- Obtain blood for laboratory studies (glucose, electrolytes, toxicology)
Treatment Algorithm
First-Line Treatment (0-10 minutes)
- Lorazepam 0.05 mg/kg IV (maximum 4 mg) administered at 2 mg/min 2
- Success rate: approximately 65% 1
- Key adverse effect: respiratory depression
- If IV access is unavailable, consider midazolam 0.2 mg/kg IM (maximum 6 mg) 1
Second-Line Treatment (10-30 minutes)
If seizures continue or recur after 10-15 minutes:
- Additional lorazepam 4 mg IV may be administered 2
- PLUS one of the following:
Third-Line Treatment (Refractory Status Epilepticus, >30 minutes)
If seizures persist despite first and second-line treatments:
- Phenobarbital: 10-20 mg/kg IV (success rate: 58%) 1
- If still refractory, consider general anesthesia with:
- Propofol
- Midazolam
- Pentobarbital/thiopental
Maintenance Therapy
After seizure control is achieved:
- Lorazepam: 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 1
- Levetiracetam: 15 mg/kg (maximum 1,500 mg) IV every 12 hours 1
- Phenobarbital: 1-3 mg/kg IV every 12 hours (if used) 1
Monitoring Requirements
- Continuous cardiorespiratory monitoring (77% risk of hypotension) 1
- Frequent neurological assessments
- EEG monitoring for high-risk populations or if patient requires neuromuscular blockade
- Laboratory monitoring: baseline renal and hepatic function, periodic electrolytes, drug levels when appropriate 1
Special Considerations
- Equipment for airway management must be immediately available before administering benzodiazepines 2
- Status epilepticus may result from correctable causes (hypoglycemia, hyponatremia, toxic/metabolic derangements) that must be identified and treated 2
- Consider neurology consultation if patient fails to respond to initial treatment 2
- Non-convulsive status epilepticus should be considered in patients who don't regain consciousness after convulsive seizures stop 1
Common Pitfalls and Caveats
- Delaying treatment beyond 5-7 minutes increases risk of neurological damage 3
- Underdosing first-line medications (particularly benzodiazepines)
- Failing to prepare for respiratory depression when administering benzodiazepines
- Not considering non-convulsive status epilepticus in patients who remain unresponsive
- Failing to identify and treat underlying causes
- Subtle status epilepticus (coma with ictal EEG discharges) has lower treatment success rates (7.7-24.2%) compared to overt status epilepticus 4
The protocol outlined above represents the most current evidence-based approach to managing status epilepticus, with lorazepam showing superiority as first-line treatment compared to phenytoin alone 4.