What is the management of status epilepticus (seizure lasting more than 5 minutes or 2 or more seizures between which the patient doesn't return to baseline) in the emergency room (ER)?

Status Epilepticus Management in the Emergency Room

The management of status epilepticus in the emergency room should follow a stepwise approach with benzodiazepines as first-line treatment, followed by antiepileptic drugs, and potentially anesthetic agents for refractory cases, with the primary goal of stopping seizure activity within 5 minutes of presentation. 1

Definition and Recognition

Status epilepticus is defined as:

• Seizures lasting more than 5 minutes
• Multiple seizures without return to baseline consciousness between episodes 2, 1

Initial Management (0-5 minutes)

1. Ensure patient safety and stabilization:

   • Place patient in recovery position
   • Clear area around patient to prevent injury
   • Establish IV access
   • Secure airway, breathing, and circulation 2, 1
   • Do not restrain the patient or place anything in their mouth 2

2. Immediate monitoring:

   • Vital signs (BP, HR, RR, O2 saturation)
   • Continuous cardiac monitoring
   • Pulse oximetry 1

3. Equipment preparation:

   • Have airway management equipment immediately available 3

First-Line Treatment (5-20 minutes)

Administer benzodiazepines immediately:

• IV Lorazepam: 0.1 mg/kg (max 4 mg) given slowly (2 mg/min) - preferred if IV access available 3, 4

  • If seizures continue after 10-15 minutes, may give additional 4 mg dose 3

• IM Midazolam: 10 mg (>40 kg) or 5 mg (13-40 kg) - if IV access not available 5

  • Studies show IM midazolam is at least as effective as IV lorazepam in prehospital settings 5

Second-Line Treatment (20-40 minutes)

If seizures persist after benzodiazepine administration, proceed to one of these options:

• Levetiracetam: 60 mg/kg IV (max 4500 mg) over 10 minutes 1
• Valproate: 30 mg/kg IV over 10 minutes (88% efficacy, less hypotension) 2, 1
• Fosphenytoin: 20 mg PE/kg IV at max 150 mg PE/min (56% efficacy, higher risk of hypotension) 2, 1

Key considerations for second-line agent selection:

• Valproate appears to have higher efficacy (88%) compared to phenytoin (56%) 2, 1
• Avoid valproate in patients with liver disease 1
• Levetiracetam is preferred in patients with hepatic dysfunction 1

Refractory Status Epilepticus (>40 minutes)

If seizures continue after second-line therapy:

1. Transfer to ICU with continuous EEG monitoring 1

2. Anesthetic agents:

   • Propofol: 2 mg/kg IV bolus, followed by 5 mg/kg/hr infusion 2
   • Midazolam: 0.2 mg/kg IV bolus, followed by 0.1-2 mg/kg/hr infusion 1
   • Consider ketamine in super-refractory cases: 1-2 mg/kg IV 6

Concurrent Diagnostic Workup

1. Laboratory studies:

   • Serum glucose (immediate fingerstick and formal lab)
   • Electrolytes, BUN, creatinine
   • Complete blood count
   • Toxicology screen if indicated
   • Antiepileptic drug levels (if on medications)
   • Consider lumbar puncture if infection suspected 1

2. Neuroimaging:

   • CT head to rule out structural lesions
   • MRI preferred when patient is stable 1

3. EEG monitoring:

   • Continuous EEG monitoring for patients who don't regain consciousness
   • Essential to detect non-convulsive status epilepticus 1, 7

Treatment of Underlying Causes

Identify and treat potential underlying causes:

• Hypoglycemia
• Electrolyte abnormalities (especially hyponatremia)
• Infection (meningitis, encephalitis)
• Stroke or intracranial hemorrhage
• Medication toxicity or withdrawal
• Metabolic derangements 1, 3

Disposition

• Patients with controlled seizures who return to baseline may be discharged with neurology follow-up
• Patients with refractory status epilepticus require ICU admission
• Mortality increases significantly (up to 65%) in refractory cases 1, 7

Common Pitfalls to Avoid

• Delay in treatment - seizures lasting >5 minutes should be treated immediately
• Inadequate benzodiazepine dosing - underdosing is common and reduces efficacy
• Failure to prepare for respiratory depression - have airway equipment ready
• Missing non-convulsive status - obtain EEG for patients who don't return to baseline
• Overlooking underlying causes - comprehensive workup is essential 1, 7

Status epilepticus is a true neurological emergency with significant morbidity and mortality. Prompt recognition and aggressive treatment following this protocol can significantly improve outcomes.