What are the steps for the acute management of status epilepticus?

Acute Management of Status Epilepticus: Simulation Guide

The acute management of status epilepticus requires immediate intervention with benzodiazepines as first-line therapy, followed by antiseizure medications, and escalation to anesthetic agents for refractory cases, with simultaneous assessment and treatment of underlying causes. 1, 2

Team Roles and Responsibilities

• Team Leader: Coordinates the team, makes treatment decisions, and ensures adherence to protocol 3
• Record Keeper: Documents medications, timing, vital signs, and response to interventions 3
• Med Prep/Crash Cart: Prepares medications according to protocol and ensures equipment availability 3
• IV Admin: Establishes and maintains IV access, administers medications as directed 3
• Communication with Family: Updates family members, obtains relevant history 3
• Airway: Manages airway, provides oxygen, prepares for potential intubation 4, 3
• Airway Assist: Assists with airway management, suction, positioning 4, 3
• Assessment/Exam/Intervention: Performs neurological assessments, monitors seizure activity 3
• Assessment/Exam/Intervention Monitor: Records findings, assists with interventions 3

Initial Assessment and Stabilization (0-5 minutes)

• Assess circulation, airway, and breathing (CAB) and provide airway protection as needed 5, 1
• Administer high-flow oxygen to prevent hypoxia, which can worsen seizures 5, 1
• Establish IV access for medication administration 1, 3
• Check blood glucose level immediately to rule out hypoglycemia as a cause 5
• Obtain vital signs including temperature to identify potential infectious causes 1, 3
• Position patient to prevent aspiration and maintain airway patency 4, 3

First-Line Treatment (5-10 minutes)

• Administer lorazepam 0.1 mg/kg IV (maximum 4 mg) at 2 mg/min; may repeat once after 5-10 minutes if seizures continue 1, 4
• Monitor respiratory status closely as benzodiazepines can cause respiratory depression 4
• Prepare equipment for airway management including bag-valve-mask and intubation supplies 4, 3
• Begin cardiac monitoring to detect arrhythmias or hemodynamic instability 3

Second-Line Treatment (10-30 minutes)

• If seizures persist after benzodiazepines, administer one of the following 5, 1:
  • Fosphenytoin 20 mg/kg PE IV at 150 mg/min 1
  • Valproate 30 mg/kg IV at 6 mg/kg/hour (preferred if concerned about hypotension) 5, 1
  • Levetiracetam 40 mg/kg IV (maximum 2,500 mg) 5, 1
• Continue to monitor vital signs and be prepared to treat hypotension, especially with phenytoin/fosphenytoin 5, 1
• Consider EEG monitoring if available, especially if patient is paralyzed or sedated 1, 3

Management of Refractory Status Epilepticus (>30 minutes)

• If seizures continue after second-line therapy, transfer to ICU and consider the following 5, 3:
  • Phenobarbital 10-20 mg/kg IV (maximum 1,000 mg) at 50-100 mg/min 5, 1
  • Propofol 1-2 mg/kg IV bolus, followed by 2-10 mg/kg/hour infusion 1, 3
  • Midazolam continuous infusion 3
• Initiate continuous EEG monitoring to detect ongoing seizure activity 5, 3
• Consider intubation and mechanical ventilation for airway protection and respiratory support 4, 3

Simultaneous Evaluation for Underlying Causes

• Obtain laboratory studies to identify metabolic abnormalities 5, 1:
  • Electrolytes (sodium, calcium, magnesium)
  • Complete blood count
  • Toxicology screen
  • Anticonvulsant drug levels if applicable
• Consider neuroimaging (CT or MRI) once patient is stabilized 5, 1
• Perform lumbar puncture if infection is suspected and there are no contraindications 5, 1
• Treat identified causes such as hypoglycemia, hyponatremia, infection, or drug withdrawal 5, 2

Maintenance Therapy and Monitoring

• After seizure cessation, continue maintenance doses of antiseizure medications 5, 1:
  • Levetiracetam 15-30 mg/kg IV every 12 hours 5
  • Phenobarbital 1-3 mg/kg IV every 12 hours if used 5
  • Valproate or phenytoin at appropriate maintenance doses 5, 1
• Monitor for adverse effects of medications, including respiratory depression, hypotension, and cardiac arrhythmias 5, 4
• Continue close neurological monitoring for recurrent seizures or changes in mental status 3, 6

Common Pitfalls and Caveats

• Underdosing of benzodiazepines is common and leads to treatment failure; use adequate doses 1, 6
• Delayed progression to second-line agents increases risk of refractory status epilepticus 3, 6
• Failure to identify and treat underlying causes can lead to recurrent seizures 5, 2
• Inadequate monitoring for respiratory depression after benzodiazepine administration 4
• Not recognizing non-convulsive status epilepticus in patients with altered mental status 1, 3
• Overlooking drug interactions between antiseizure medications and other medications 5, 1

Special Considerations for Simulation

• Include time-sensitive decision points to emphasize the importance of rapid intervention 6
• Incorporate changes in patient status to test team adaptability 3
• Simulate complications such as respiratory depression or hypotension to practice management 4, 3
• Include family communication scenarios to practice information gathering and updates 3
• Practice team communication and closed-loop communication during critical interventions 3