What is the management of status epilepticus?

Management of Status Epilepticus

Status epilepticus requires immediate treatment with benzodiazepines as first-line therapy, followed by intravenous phenytoin, fosphenytoin, or valproate as second-line agents if seizures persist, and escalation to levetiracetam, propofol, or barbiturates for refractory cases. 1

Definition and Significance

Status epilepticus is a life-threatening neurological emergency characterized by:

• Prolonged seizure activity (traditionally defined as ≥30 minutes, though some propose shortening this to 5 minutes) 1
• Recurrent seizures without full recovery of consciousness between episodes 1
• Mortality rates of 5-22%, increasing to 65% in refractory cases 1

Treatment Algorithm

Step 1: Initial Stabilization

• Secure airway, breathing, and circulation
• Monitor vital signs
• Establish intravenous access
• Position patient to prevent injury
• Administer supplemental oxygen if needed 2

Step 2: First-Line Treatment - Benzodiazepines

• Lorazepam 4 mg IV given slowly (2 mg/min) is the preferred first-line agent 2
• If seizures continue after 10-15 minutes, an additional 4 mg IV dose may be administered 2
• Alternative benzodiazepines can be used if IV access is not available 3

Step 3: Second-Line Treatment (for benzodiazepine-resistant status)

• Administer one of the following (Level B recommendation): 1
  • Phenytoin: 18-20 mg/kg IV at 50 mg/min
  • Fosphenytoin: 18-20 mg/kg PE (phenytoin equivalents) IV at 150 mg/min
  • Valproate: 30 mg/kg IV at 6 mg/kg/hour

Note: The ESETT trial showed all three medications (levetiracetam, fosphenytoin, valproate) have similar efficacy, stopping seizures in approximately 50% of cases 1

Step 4: Refractory Status Epilepticus Management

• For seizures continuing after first and second-line treatments (Level C recommendation): 1
  • Levetiracetam: 30 mg/kg IV at 5 mg/kg/min
  • Propofol: 1-2 mg/kg IV bolus, followed by 2-10 mg/kg/hour infusion
  • Barbiturates: Phenobarbital 20 mg/kg IV at 50-100 mg/min

Step 5: Super-Refractory Status Epilepticus

• Consider anesthetic doses of midazolam, propofol, or barbiturates 1
• Ketamine may be considered in early phase 3 status epilepticus 3
• Continuous EEG monitoring is essential at this stage 4

Special Considerations

Monitoring and Supportive Care

• Continuous vital sign monitoring
• Frequent neurological assessments
• Prevent and treat hyperthermia and rhabdomyolysis 5
• Identify and correct precipitating factors: 1
  • Hypoglycemia
  • Hyponatremia
  • Hypoxia
  • Drug toxicity
  • CNS infection
  • Stroke or hemorrhage
  • Alcohol withdrawal

Cautions and Pitfalls

• Respiratory depression is the most important risk with benzodiazepine use; maintain airway patency and monitor respiration closely 2
• Phenytoin/fosphenytoin can cause hypotension (12% of cases) versus valproate (0%) 1
• Underdosing of antiepileptic medications is associated with prolonged status and increased medication requirements 6
• Concomitant use of benzodiazepines with opioids may result in profound sedation, respiratory depression, and death 2

EEG Monitoring

• Continuous EEG monitoring is critical for management of both convulsive and non-convulsive status epilepticus 4
• Essential for patients with refractory status epilepticus to guide treatment 1

Comparative Efficacy of Second-Line Agents

• Valproate has shown efficacy rates of 68-88% in refractory status epilepticus 1
• Levetiracetam demonstrated efficacy rates of 67-73% in various studies 1
• Phenytoin/fosphenytoin showed 56-84% efficacy in terminating status epilepticus 1

The Veterans Administration cooperative study showed that when treating status epilepticus, first-line treatment success rates were: lorazepam 64.9%, phenobarbital 58.2%, diazepam/phenytoin 55.8%, and phenytoin alone 43.6% 5.