What is the management approach for status epilepticus?

Status Epilepticus Management

Status epilepticus requires immediate intervention with a stepwise approach starting with benzodiazepines, followed by second-line anticonvulsants, and progressing to anesthetic agents for refractory cases. 1

Initial Assessment and Management

• Assess circulation, airway, and breathing (CAB) and provide airway protection interventions, administer high-flow oxygen, and check blood glucose level 2
• Simultaneously search for and treat underlying causes including hypoglycemia, hyponatremia, hypoxia, drug toxicity, CNS infections, stroke, hemorrhage, and withdrawal syndromes 2, 1
• Equipment necessary to maintain a patent airway should be immediately available prior to administering medications 3

First-Line Treatment: Benzodiazepines

Adult Dosing:

• Lorazepam: 4 mg IV given slowly (2 mg/min); may repeat once after 10-15 minutes if seizures continue 3
• Alternative: Diazepam or midazolam if lorazepam unavailable 4

Pediatric Dosing:

• Lorazepam: 0.1 mg/kg (maximum 2 mg) IV; may repeat once after at least 1 minute 2

Second-Line Treatment (if seizures persist after benzodiazepines)

Emergency physicians should administer one of the following anticonvulsant medications 2:

Recommended Options:

• Valproate: 30 mg/kg IV at 5-6 mg/kg/min (Level B recommendation) 2, 1

  • Shows similar or superior efficacy to phenytoin (88% vs 84%)
  • Significantly lower risk of hypotension (0% vs 12% with phenytoin)

• Phenytoin/Fosphenytoin: 20 mg/kg IV at maximum 50 mg/min (Level B recommendation) 2

  • Requires continuous ECG and blood pressure monitoring
  • Consider "high-dose phenytoin" up to 30 mg/kg if initial dose fails 2

• Levetiracetam: 30-40 mg/kg IV (maximum 2,500 mg) (Level C recommendation) 2

  • Similar efficacy to valproate (73% vs 68%)
  • Favorable safety profile with no significant cardiovascular effects

Refractory Status Epilepticus Management

If seizures continue despite first and second-line treatments, transfer patient to intensive care unit and consider 2:

• Phenobarbital: 10-20 mg/kg IV loading dose (maximum 1,000 mg) 2
• Propofol: 2 mg/kg bolus followed by 3-7 mg/kg/hour infusion 1, 5
  • Advantage of shorter mechanical ventilation time compared to barbiturates
• Midazolam infusion: For ongoing seizure control 6, 5
• Pentobarbital: Consider for super-refractory cases 2, 5

Continuous Monitoring

• Implement continuous EEG monitoring for refractory status epilepticus 2, 5
• Monitor vital signs continuously, especially with phenytoin/fosphenytoin administration 1
• All patients who do not recover consciousness should be monitored with EEG 6

Maintenance Therapy After Resolution

• Lorazepam: 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 2
• Levetiracetam: 15-30 mg/kg IV every 12 hours 2
• Phenobarbital: 1-3 mg/kg IV every 12 hours if used 2

Prognosis and Outcomes

• Mortality ranges from 10-15% overall but increases with refractory (25%) and super-refractory cases (40%) 5
• Outcomes primarily depend on underlying etiology, age, duration of status epilepticus, and adequacy of care 4
• CNS infections are associated with the highest mortality and morbidity rates 4

Common Pitfalls to Avoid

• Inadequate dosing of benzodiazepines - use full recommended doses 7
• Delays in progressing to second-line agents - move to next treatment step if seizures continue after 5-10 minutes 1
• Failure to monitor for respiratory depression with benzodiazepines and barbiturates 2
• Overlooking treatable underlying causes while focusing only on seizure termination 3, 8
• Not providing continuous EEG monitoring in patients with refractory status epilepticus 5