What is the management of a patient in status epilepticus?

From the Guidelines

Management of a patient in seizure requires immediate action to ensure safety and stop the seizure, with the primary goal of reducing morbidity and mortality, as emphasized in a recent study published in 2024 1. To achieve this, the following steps should be taken:

• Place the patient on their side to prevent aspiration and clear the area of harmful objects.
• Do not restrain the patient or place anything in their mouth.
• For seizures lasting more than 5 minutes (status epilepticus), administer benzodiazepines: lorazepam 4mg IV (preferred), diazepam 10mg IV, or midazolam 10mg IM/intranasal if IV access is unavailable.
• If seizures persist after 5-10 minutes, give a second dose of benzodiazepines.
• For refractory seizures, the use of levetiracetam, fosphenytoin, or valproate will result in cessation of seizures in approximately half of all patients, as reported in the 2024 study 1.
• Continuously monitor vital signs, oxygen saturation, and be prepared for respiratory support.
• After the seizure resolves, perform a thorough neurological examination and investigate the underlying cause through laboratory tests (electrolytes, glucose, toxicology), neuroimaging, and possibly lumbar puncture. The benefits of early treatment and cessation of status epilepticus include a reduction in morbidity and mortality, with limited harms, as noted in the study 1. Key considerations in the management of seizures include:
• Prompt treatment to prevent neuronal damage and complications
• Individualized treatment based on seizure type and etiology
• Regular follow-up to adjust treatment as needed
• Monitoring for potential adverse drug reactions, as mentioned in the study 1.

From the FDA Drug Label

The treatment of status, however, requires far more than the administration of an anticonvulsant agent. It involves observation and management of all parameters critical to maintaining vital function and the capacity to provide support of those functions as required. Ventilatory support must be readily available The use of benzodiazepines, like lorazepam injection, is ordinarily only an initial step of a complex and sustained intervention which may require additional interventions (e.g., concomitant intravenous administration of phenytoin). Because status epilepticus may result from a correctable acute cause such as hypoglycemia, hyponatremia, or other metabolic or toxic derangement, such an abnormality must be immediately sought and corrected. Furthermore, patients who are susceptible to further seizure episodes should receive adequate maintenance antiepileptic therapy

The management of a patient in seizure involves:

• Observation and management of vital functions
• Ventilatory support should be readily available
• Initial administration of an anticonvulsant agent like lorazepam, followed by possible additional interventions
• Identification and correction of any underlying metabolic or toxic cause
• Adequate maintenance antiepileptic therapy for patients susceptible to further seizures 2

From the Research

Management of Seizures

• The management of seizures, particularly status epilepticus, is crucial for preventing long-term neurological damage and improving patient outcomes 3, 4, 5, 6.
• Benzodiazepines, such as lorazepam, diazepam, and clonazepam, are commonly used as first-line treatments for acute seizures and status epilepticus due to their potent and effective properties 3, 4, 6.

Choice of Benzodiazepine

• Lorazepam is often preferred over diazepam for the initial management of status epilepticus due to its longer duration of action and smaller volume of distribution of unbound drug, allowing for more orderly administration of antiepileptic drugs for long-term seizure control 3, 4.
• A meta-analysis of randomized controlled trials found that intravenous lorazepam was better than intravenous diazepam for the cessation of adult status epilepticus, with a significantly superior effect of lorazepam over diazepam (RR, 1.24; 95% CI, 1.03-1.49) 4.
• In children, lorazepam has been found to be as efficacious and safe as diazepam-phenytoin combination for the treatment of convulsive status epilepticus, with no statistically significant difference in the median time taken to stop the seizure or the number of subjects requiring more than one dose of the study drug 5.

Treatment of Benzodiazepine-Resistant Status Epilepticus

• In cases of benzodiazepine-resistant convulsive status epilepticus, other antiepileptic drugs such as valproate, levetiracetam, and phenobarbital can be used as first-line therapy, with efficacy rates ranging from 68.5% to 75.7% 7.
• Phenytoin is not recommended as a first-line treatment for benzodiazepine-resistant status epilepticus due to its lower efficacy rate of 50.2% (95% CI: 34.2-66.1%) 7.
• Lacosamide is not recommended for routine use due to insufficient data, and randomized controlled trials are needed to further evaluate its effectiveness in this setting 7.