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 Clinical Significance

• Status epilepticus is defined as a seizure lasting longer than 5 minutes or multiple seizures without return to neurologic baseline, requiring prompt intervention. 1, 2
• It represents a life-threatening neurological emergency with mortality rates of 5-22%, increasing to 65% in refractory cases. 1
• Up to 5% of adults with epilepsy will experience at least one episode of status epilepticus in their lifetime. 2

Treatment Algorithm

First-Line Treatment

• Administer benzodiazepines immediately as first-line therapy. 1, 3
• For adults, lorazepam 4 mg IV given slowly (2 mg/min) is recommended. If seizures continue after 10-15 minutes, an additional 4 mg IV dose may be administered. 4
• Equipment to maintain a patent airway should be immediately available prior to administering benzodiazepines. 4

Second-Line Treatment (if seizures persist after benzodiazepines)

• The American College of Emergency Physicians recommends one of the following (Level B recommendation): 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, 3

Refractory Status Epilepticus Treatment

• For cases unresponsive to first and second-line treatments, consider (Level C recommendation): 1
  • Levetiracetam: 30 mg/kg IV at 5 mg/kg/min (efficacy rate 67-73%) 1, 3
  • Propofol: 1-2 mg/kg IV bolus, followed by 2-10 mg/kg/hour infusion 1, 3
  • Barbiturates (phenobarbital): 20 mg/kg IV at 50-100 mg/min 1

Comparative Efficacy and Safety Considerations

• Valproate shows similar or superior efficacy to phenytoin (88% vs 84%) with significantly lower risk of hypotension (0% vs 12%). 3
• Phenytoin/fosphenytoin requires continuous ECG and blood pressure monitoring due to higher risk of cardiovascular adverse effects. 3
• Levetiracetam has efficacy similar to valproate (73% vs 68%) with a favorable safety profile and no significant cardiovascular effects. 3
• Propofol has the advantage of shorter mechanical ventilation time compared to barbiturates (4 vs 14 days) in refractory cases. 3

Concurrent Management Priorities

• Simultaneously investigate and treat underlying causes while administering anticonvulsants. 2, 3

• Identify and correct precipitating factors, including: 1

  • Hypoglycemia
  • Hyponatremia
  • Hypoxia
  • CNS infection
  • Stroke or hemorrhage
  • Drug toxicity
  • Withdrawal syndromes 2

• Establish intravenous access, monitor vital signs, maintain an unobstructed airway, and have artificial ventilation equipment available. 4

• Consider EEG monitoring for detecting nonconvulsive status epilepticus, especially in patients with persistent altered consciousness. 1

Common Pitfalls and Caveats

• Infra-therapeutic dosing of antiepileptic drugs is associated with prolonged status epilepticus and need for additional medications. 5
• Incorrect sequence of drug administration correlates with unfavorable outcomes. 5
• Failure to recognize and treat the underlying cause may lead to persistent seizures despite appropriate anticonvulsant therapy. 4
• Delay in treatment escalation increases the risk of neuronal injury and mortality. 6
• Continuous EEG monitoring is necessary if neuromuscular blockade is required to reduce metabolic effects of prolonged seizures. 7

Special Considerations

• The "time is brain" concept applies to status epilepticus, emphasizing the need for rapid intervention to prevent neurological damage. 8
• Status epilepticus becomes increasingly resistant to treatment as it progresses due to changes in neurotransmission that increase excitatory mechanisms and decrease inhibitory mechanisms. 6
• Patient age is a major determinant of prognosis in status epilepticus. 2