What is the treatment for status epilepticus?

Treatment of Status Epilepticus

The treatment of status epilepticus requires immediate administration of benzodiazepines as first-line therapy, followed by phenytoin, fosphenytoin, or valproate as second-line agents, and escalation to levetiracetam, propofol, or barbiturates for refractory cases. 1

Definition and Initial Assessment

• Status epilepticus is defined as a seizure lasting longer than 5 minutes or multiple seizures without a return to neurologic baseline 2, 3
• It represents a medical emergency with mortality rates of 5-22%, increasing to 65% in refractory cases 1
• Simultaneous investigation for underlying causes (hypoglycemia, hyponatremia, infections, stroke, drug withdrawal) is essential while initiating treatment 1, 3

Treatment Algorithm

First-Line Treatment: Benzodiazepines

• Intravenous lorazepam is superior to intravenous diazepam or phenytoin alone for seizure cessation 4
• Recommended dosing for lorazepam: 4 mg IV given slowly (2 mg/min) for adults 5
• If seizures continue after 10-15 minutes, an additional 4 mg IV dose may be administered 5
• When IV access is unavailable, intramuscular midazolam is more effective than IV lorazepam for pre-hospital management 4

Second-Line Treatment (Level B recommendation)

• If seizures persist despite optimal benzodiazepine administration, administer one of the following 1:
  • Phenytoin: 18-20 mg/kg IV at 50 mg/min 1
  • Fosphenytoin: 18-20 mg/kg PE (phenytoin equivalents) IV at 150 mg/min 1
  • Valproate: 30 mg/kg IV at 6 mg/kg/hour 1

Third-Line Treatment for Refractory Status Epilepticus (Level C recommendation)

• For seizures continuing despite second-line therapy, consider 2, 1:
  • Levetiracetam: 30 mg/kg IV at 5 mg/kg/min (efficacy rate 67-73%) 1
  • Propofol: 1-2 mg/kg IV bolus, followed by 2-10 mg/kg/hour infusion (requires respiratory support) 1
  • Phenobarbital: 20 mg/kg IV at 50-100 mg/min (can cause respiratory depression and hypotension) 1

Monitoring and Additional Considerations

• Equipment to maintain a patent airway should be immediately available prior to administering anticonvulsants 5
• EEG monitoring is crucial for detecting nonconvulsive status epilepticus, especially in patients with persistent altered consciousness 2, 6
• Consider emergent EEG in patients suspected of being in nonconvulsive status epilepticus, those who have received long-acting paralytics, or patients in drug-induced coma 2

Special Considerations

• Phenytoin/fosphenytoin can cause hypotension in 12% of cases compared to valproate (0%) 1
• Super-refractory status epilepticus (continuing despite midazolam or propofol) may require ketamine or barbiturates 7
• Continuous video EEG is necessary for management of refractory and super-refractory status epilepticus 7
• Short-term mortality increases from 10% in responsive cases to 25% in refractory and nearly 40% in super-refractory status epilepticus 7

Pitfalls to Avoid

• Delaying treatment beyond 5 minutes of seizure activity can lead to receptor changes that increase brain damage risk 6
• Underdosing benzodiazepines in the initial treatment phase is a common error 6
• Failure to identify and treat underlying causes while managing seizures 1, 3
• Neglecting respiratory support when administering multiple anticonvulsants with sedating properties 5