What is the role of lidocaine (bolus and infusion) in the treatment of status epilepticus?

Lidocaine for Status Epilepticus: Limited Historical Role, Not Recommended in Modern Guidelines

Lidocaine is not included in current evidence-based treatment algorithms for status epilepticus and should not be used as a standard therapy. Modern guidelines from the American College of Emergency Physicians and other major societies do not recommend lidocaine at any stage of status epilepticus treatment 1, 2, 3.

Why Lidocaine Is Not Recommended

Absence from Current Guidelines

• No major guideline includes lidocaine in the treatment algorithm for status epilepticus, despite comprehensive reviews of available agents 1, 2, 3
• The American College of Emergency Physicians' 2014 critical issues guideline extensively reviews first-line, second-line, and refractory status epilepticus treatments without mentioning lidocaine 1
• The most recent status epilepticus treatment protocols (2025) outline benzodiazepines, phenytoin/fosphenytoin, valproate, levetiracetam, phenobarbital, midazolam, propofol, and pentobarbital—but not lidocaine 2, 3

Limited and Outdated Evidence

• The only available evidence is a single 1988 case series of 8 patients, which is now over 35 years old and represents Class III evidence at best 4
• This historical study showed lidocaine controlled convulsive status epilepticus with 100-200 mg bolus doses and continuous infusion at 3.5 mg/kg/h, but this has never been validated in modern controlled trials 4
• No randomized controlled trials, comparative effectiveness studies, or modern case series support lidocaine use for status epilepticus 5, 6

Evidence-Based Treatment Algorithm You Should Follow Instead

Stage 1: Early Status Epilepticus (0-5 minutes)

• Benzodiazepines are first-line treatment with the strongest evidence from multiple randomized controlled trials 1, 5, 7
• Options include IV lorazepam, IM midazolam (0.2 mg/kg, max 6 mg), or intranasal midazolam 8, 7

Stage 2: Established Status Epilepticus (After benzodiazepine failure)

Choose one of these equally effective second-line agents 1, 2, 3:

• Valproate 20-30 mg/kg IV over 5-20 minutes: 88% efficacy with 0% hypotension risk (superior safety profile to phenytoin) 2, 3
• Levetiracetam 30 mg/kg IV over 5 minutes: 68-73% efficacy with minimal adverse effects 1, 2
• Fosphenytoin 20 mg PE/kg IV at max 50 mg/min: 84% efficacy but 12% hypotension risk, requires continuous ECG monitoring 1, 3
• Phenobarbital 20 mg/kg IV over 10 minutes: 58.2% efficacy but higher risk of respiratory depression 1, 2

Stage 3: Refractory Status Epilepticus (After second-line failure)

Anesthetic agents are required 1, 2, 8:

• Midazolam infusion: 0.15-0.20 mg/kg IV load, then 1 mg/kg/min continuous infusion, titrate up by 1 mg/kg/min every 15 minutes to max 5 mg/kg/min 8
• Propofol: 2 mg/kg bolus, then 3-7 mg/kg/hour infusion—requires mechanical ventilation but shorter ventilation time than barbiturates (4 vs 14 days) 1, 2
• Pentobarbital: 13 mg/kg bolus, then 2-3 mg/kg/hour infusion—92% efficacy but more hypotension than propofol 1, 2

Critical Pitfalls to Avoid

• Do not delay proven therapies to try unvalidated agents like lidocaine—"time is brain" in status epilepticus 5
• Infra-therapeutic dosing is associated with prolonged status epilepticus and worse outcomes; use full guideline-recommended doses 9
• Incorrect drug sequencing increases the number of medications needed and prolongs seizure duration 9
• Simultaneously search for and treat underlying causes: hypoglycemia, hyponatremia, hypoxia, drug toxicity, CNS infection, stroke, hemorrhage 2, 3

The Bottom Line on Lidocaine

While the 1988 case series suggested lidocaine might work as a "diazepam substitute" in elderly patients with COPD 4, this approach has been superseded by:

• Better benzodiazepine delivery methods (IM and intranasal routes that avoid respiratory depression concerns) 8, 7
• Multiple proven second-line agents with robust evidence bases 1, 2, 3
• Modern anesthetic protocols for refractory cases 1, 2, 8

There is no clinical scenario in modern practice where lidocaine should be chosen over the evidence-based agents listed in current guidelines.