What is the treatment for status epilepticus?

Treatment of Status Epilepticus

The first-line treatment for status epilepticus is intravenous lorazepam at a dose of 0.05 mg/kg (maximum 4 mg) administered slowly (2 mg/min), with a success rate of 65%. 1, 2

Treatment Algorithm

First-Line Treatment (0-5 minutes)

• Lorazepam 0.05 mg/kg IV (maximum 4 mg) administered slowly at 2 mg/min
• If seizures continue after 10-15 minutes, an additional 4 mg dose may be administered 2
• Ensure equipment to maintain patent airway is immediately available
• Start IV infusion, monitor vital signs, maintain unobstructed airway
• Have artificial ventilation equipment ready

Second-Line Treatment (20-40 minutes if seizures persist)

Choose one of the following:

• Valproate: 20-30 mg/kg IV (88% success rate)
• Levetiracetam: 30-50 mg/kg IV (44-73% success rate)
• Phenytoin: 18-20 mg/kg IV (56% success rate)
• Fosphenytoin: Consider as alternative to phenytoin due to better safety profile 1

Third-Line Treatment (Refractory Status Epilepticus)

For cases unresponsive to first and second-line treatments:

• Pentobarbital: Associated with fewer treatment failures (8%) compared to propofol (27%) and midazolam (20%) 1
• Midazolam: Loading dose 0.15-0.20 mg/kg, followed by continuous infusion starting at 1 mg/kg per min, increasing by 1 mg/kg per min every 15 min until seizures stop 1
• Propofol: Loading dose 50-75 mg/kg over 10-60 min, followed by infusion of 0.50-0.75 mg/kg per min 1

Monitoring and Supportive Care

• Respiratory monitoring: Continuous oxygen saturation monitoring due to risk of apnea, especially when combining sedative agents 1
• Hemodynamic monitoring: Continuous blood pressure and ECG monitoring due to high risk of hypotension (77% of cases) 1
• Laboratory monitoring: Baseline renal and hepatic function, periodic electrolytes, and drug levels when appropriate 1

Medication Considerations and Adverse Effects

Medication	Key Adverse Effects	Special Considerations
Lorazepam	Respiratory depression	First-line due to higher efficacy (64.9%) compared to phenytoin (43.6%) [3]
Valproate	GI disturbances, tremor	High success rate (88%) with minimal cardiovascular effects
Levetiracetam	Minimal adverse effects	Good option for patients with hepatic or cardiac disease
Phenytoin	Hypotension, cardiac dysrhythmias, purple glove syndrome	Requires cardiac monitoring during administration
Phenobarbital	Respiratory depression, hypotension	Consider for refractory cases

Maintenance Therapy

After initial control of seizures, maintenance doses should be administered:

• Lorazepam: 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses
• Levetiracetam: 15 mg/kg (maximum 1,500 mg) IV every 12 hours
• Phenobarbital: 1-3 mg/kg IV every 12 hours (if used) 1

Special Populations and Considerations

• Non-convulsive status epilepticus: High-risk populations include elderly patients on psychotropic medications, ICU patients, post-convulsive seizure patients, and patients with encephalopathy 1
• Underlying causes: Status epilepticus may result from correctable causes such as hypoglycemia, hyponatremia, or other metabolic/toxic derangements that must be immediately identified and corrected 2
• Cardiac conditions: Avoid phenytoin due to risk of dysrhythmias; consider levetiracetam or valproate
• Liver disease: Avoid valproate; prefer levetiracetam
• Renal impairment: Exercise caution with frequent dosing over short periods 2

Common Pitfalls to Avoid

1. Delayed treatment: Status epilepticus is a medical emergency requiring immediate intervention within 5 minutes of onset 4
2. Inadequate dosing: Underdosing of benzodiazepines is common and reduces efficacy
3. Failure to prepare for respiratory depression: Always have airway equipment immediately available before administering IV lorazepam 2
4. Overlooking underlying causes: Always search for and correct metabolic derangements, toxins, or other reversible causes 2
5. Inadequate monitoring: Continuous cardiorespiratory monitoring is essential due to high risk of complications 1

Time is critical in status epilepticus management, as prolonged seizures lead to receptor changes that increase resistance to treatment and risk of brain injury 4. The Established Status Epilepticus Treatment Trial (ESETT) found similar efficacy (approximately 45-47%) for levetiracetam, fosphenytoin, and valproate as second-line agents 1.