Status Epilepticus Management in the Emergency Department
For adult patients with status epilepticus in the ED, immediately administer benzodiazepines as first-line therapy, followed by intravenous fosphenytoin, levetiracetam, or valproate as equally effective second-line agents if seizures persist after optimal benzodiazepine dosing. 1, 2
Initial Stabilization and Assessment
Simultaneously with seizure treatment, immediately evaluate and correct underlying causes:
- Hypoglycemia 1, 2, 3
- Hyponatremia 1, 2, 3
- Hypoxia 1, 2
- Drug toxicity or withdrawal syndromes 1
- CNS infection 1
- Ischemic stroke or intracerebral hemorrhage 1, 2
Ensure airway management readiness: Equipment to maintain a patent airway and provide ventilatory support must be immediately available, as 16-26% of patients may require endotracheal intubation. 2, 3
First-Line Treatment: Benzodiazepines
Lorazepam 4 mg IV (given at 2 mg/min) is the preferred benzodiazepine for adults ≥18 years. 3, 4
- If seizures continue or recur after 10-15 minutes, administer an additional 4 mg IV dose slowly 3
- Lorazepam is superior to phenytoin alone (64.9% vs 43.6% success rate, p=0.002) and easier to use than diazepam plus phenytoin combinations 4
- Alternative routes when IV access unavailable: intramuscular, intranasal, or rectal administration 3, 5
Critical pitfall: Status epilepticus is defined operationally as seizures lasting >5 minutes or multiple seizures without return to baseline—do not wait 20-30 minutes to initiate treatment. 1
Second-Line Treatment: After Benzodiazepine Failure
The 2024 ACEP guidelines provide Level A evidence that fosphenytoin, levetiracetam, and valproate are equally effective second-line agents, with approximately 45-47% achieving seizure cessation within 60 minutes. 2
Medication Options (Level B Recommendation):
Fosphenytoin: 18-20 PE/kg IV 1
Valproate: 20-30 mg/kg IV at 40 mg/min 1
- Hypotension risk: 1.6% 2
- Superior to phenytoin in some studies (79% vs 25% seizure control as second-line agent, NNT 1.9) 1
- Advantage: can be given more quickly with fewer adverse effects than phenytoin 1
Levetiracetam: 30-50 mg/kg IV at 100 mg/min 1
- Hypotension risk: 0.7% (lowest of the three) 2
- Safe profile with low incidence of respiratory depression 1
Important note: The patient's home antiseizure medication does not affect the probability of stopping status epilepticus when used as a second-line agent. 2
Third-Line Treatment: Refractory Status Epilepticus
For seizures persisting after benzodiazepines and second-line agents (Level C Recommendation): 1
Phenobarbital: 10-20 mg/kg IV, may repeat 5-10 mg/kg at 10 minutes 1
- Risk: respiratory depression and hypotension 1
Propofol: 2 mg/kg IV, may repeat in 3-5 minutes; maintenance infusion 5 mg/kg/h 1
Midazolam infusion: For refractory cases 2
Pentobarbital infusion: High efficacy (92%) but 77% require vasopressor support 2
Monitoring and Ongoing Management
Consider EEG monitoring for patients with persistent altered consciousness to detect nonconvulsive status epilepticus. 2
Critical pitfall: Failing to recognize nonconvulsive status epilepticus in patients who remain altered after apparent seizure cessation can lead to ongoing neurological injury. 2
Start IV infusion, monitor vital signs continuously, and maintain unobstructed airway throughout treatment. 3
Key Clinical Pearls
- Time is critical: Prolonged status epilepticus increases morbidity and mortality—administer medications promptly without delay 5
- Do not withhold benzodiazepines in patients already on multiple anticonvulsants; this increases risk of progression to refractory status epilepticus 6
- All three second-line agents (fosphenytoin, levetiracetam, valproate) are equally effective—choice can be based on side effect profile and patient-specific factors 2
- Levetiracetam has the most favorable safety profile among second-line agents with lowest hypotension risk 2