What is the management approach for status epilepticus?

Status Epilepticus Management

Administer IV lorazepam 4 mg at 2 mg/min as first-line treatment, followed immediately by valproate 30 mg/kg IV if seizures persist after 5-10 minutes, as valproate demonstrates superior safety with 88% efficacy and 0% hypotension risk compared to phenytoin's 84% efficacy and 12% hypotension risk. 1, 2

Initial Stabilization (0-5 minutes)

• Assess and secure airway, breathing, and circulation (CAB) with high-flow oxygen administration 1
• Check blood glucose immediately and correct hypoglycemia if present 1, 3
• Establish IV access and prepare airway management equipment—ventilatory support must be immediately available 3
• Begin continuous vital sign monitoring including ECG and blood pressure 1
• Simultaneously search for reversible causes: hypoglycemia, hyponatremia, hypoxia, drug toxicity, CNS infections, stroke, hemorrhage, and withdrawal syndromes 1, 3

First-Line Treatment: Benzodiazepines (5 minutes)

• Lorazepam 4 mg IV at 2 mg/min (0.1 mg/kg, maximum 4 mg) is the preferred first-line agent 1, 3
• If seizures continue after 10-15 minutes, administer a second dose of lorazepam 4 mg IV 3
• Alternative routes when IV access unavailable: IM midazolam, intranasal midazolam, or rectal diazepam 4, 5
• Critical pitfall: Respiratory depression is the most important risk—maintain airway patency and monitor respiration continuously 3

Second-Line Treatment: Non-Sedating Antiseizure Medications (10-20 minutes)

If seizures persist after benzodiazepines, immediately escalate to second-line agents—do not delay beyond 5-10 minutes: 1

Preferred Agent: Valproate

• Valproate 30 mg/kg IV at 5-6 mg/kg/min demonstrates 88% efficacy with 0% hypotension risk, making it superior to phenytoin 1, 2
• Maximum dose typically 2,500-3,000 mg 4
• Minimal cardiovascular monitoring required compared to phenytoin 2

Alternative Agents (in order of preference):

• Levetiracetam 30-40 mg/kg IV (maximum 2,500 mg) over 5 minutes: 73% efficacy with favorable safety profile and no significant cardiovascular effects 1, 2
• Phenytoin/Fosphenytoin 20 mg/kg IV at maximum 50 mg/min: 84% efficacy but requires continuous ECG and blood pressure monitoring due to 12% hypotension risk 1, 2, 4
• Phenobarbital 20 mg/kg IV over 10 minutes: 58.2% efficacy but higher risk of respiratory depression requiring close monitoring 4, 6

Critical pitfall: Phenytoin causes significantly more hypotension than alternatives—only use when valproate or levetiracetam are contraindicated 2, 4

Refractory Status Epilepticus (20-60 minutes)

If seizures continue despite first-line and second-line agents, the patient has refractory status epilepticus requiring ICU admission and continuous EEG monitoring: 1, 7

Anesthetic Agents (choose one):

• Midazolam infusion: 0.15-0.20 mg/kg IV bolus, then 1 mg/kg/min continuous infusion, titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min 4, 6
• Propofol: 2 mg/kg bolus followed by 3-7 mg/kg/hour infusion—preferred over barbiturates due to shorter mechanical ventilation time (4 vs 14 days) 1, 2, 4
• Pentobarbital: 13 mg/kg bolus followed by 2-3 mg/kg/hour infusion—92% efficacy but more hypotension than propofol 4, 6
• Phenobarbital: 10-20 mg/kg IV loading dose (maximum 1,000 mg) for super-refractory cases 8, 1, 6

Essential Monitoring Requirements:

• Implement continuous video EEG monitoring immediately for refractory status epilepticus 1, 7
• Mechanical ventilation and respiratory support required for all anesthetic agents 4, 3
• Continuous hemodynamic monitoring with vasopressor support available 7

Critical pitfall: 25% of patients with apparent seizure cessation have continuing electrical seizures on EEG—do not assume clinical cessation equals electrical cessation 8

Super-Refractory Status Epilepticus

• Defined as seizures continuing despite anesthetic agents or reemerging after weaning 7
• Consider additional non-sedating ASM: lacosamide, brivaracetam 7
• Ketamine is increasingly used not only in stage 3 but also as a second-line option 5, 7
• Mortality approaches 40% in super-refractory cases compared to 10% in responsive cases 7

Maintenance Therapy After Seizure Cessation

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

Critical Pitfalls to Avoid

• Do not delay progression to second-line agents—move to next treatment step if seizures continue after 5-10 minutes 1
• Do not assume clinical seizure cessation equals electrical cessation—obtain EEG for persistent altered consciousness 8, 1
• Do not underestimate respiratory depression risk with benzodiazepines and barbiturates—have airway equipment immediately available 1, 3
• Do not use phenytoin as first choice for second-line therapy—valproate has superior safety profile 1, 2
• Do not delay EEG in refractory cases—25% have subclinical electrical seizures despite apparent clinical control 8
• Patients over 50 years have more profound and prolonged sedation with lorazepam—consider dose adjustment 3

Special Populations

• Pediatric patients: Lorazepam 0.1 mg/kg (maximum 2 mg) IV, may repeat once after at least 1 minute 1
• Elderly patients: No specific dose adjustment required, but expect more profound sedation 3
• Hepatic disease: No dose adjustment needed 3