What is the treatment plan with doses for status epilepticus?

Status Epilepticus Treatment Protocol

Administer IV lorazepam 4 mg at 2 mg/min immediately as first-line treatment for any actively seizing patient, followed by a second-line agent if seizures persist beyond 5 minutes. 1, 2

Immediate Actions (0-5 minutes)

• Check fingerstick glucose immediately and correct hypoglycemia while administering treatment 1
• Establish IV access, start continuous vital sign monitoring, and have airway equipment at bedside before drug administration 1, 2
• Administer lorazepam 4 mg IV at 2 mg/min (0.1 mg/kg in adults) as the first-line agent with 65% efficacy in terminating status epilepticus 1, 3
• If seizures continue after 10-15 minutes, give a second dose of lorazepam 4 mg IV at 2 mg/min 1, 2

Pediatric Dosing Modification

• For pediatric patients, use lorazepam 0.1 mg/kg IV (maximum 2 mg per dose), repeatable once after at least 1 minute 4

Second-Line Treatment (5-20 minutes after benzodiazepines)

If seizures persist after adequate benzodiazepine dosing, immediately administer one of the following second-line agents:

Preferred Second-Line Options (in order of preference based on safety profile):

• Valproate 20-30 mg/kg IV over 5-20 minutes — 88% efficacy with 0% hypotension risk, making it the safest second-line option 1
• Levetiracetam 30 mg/kg IV over 5 minutes — 68-73% efficacy with minimal cardiovascular effects 1
• Fosphenytoin 20 mg PE/kg IV at maximum rate of 150 PE/min — 84% efficacy but 12% hypotension risk; requires continuous ECG and blood pressure monitoring 1, 5
• Phenobarbital 20 mg/kg IV over 10 minutes — 58.2% efficacy but higher risk of respiratory depression 1

Critical Monitoring During Second-Line Treatment

• Continuous ECG and blood pressure monitoring is mandatory for phenytoin/fosphenytoin due to cardiovascular toxicity 1
• Be prepared for respiratory support regardless of which agent is chosen 1

Refractory Status Epilepticus (>20 minutes despite benzodiazepines + one second-line agent)

Initiate continuous EEG monitoring and proceed to anesthetic agents:

First-Choice Anesthetic Agent:

• Midazolam: 0.15-0.20 mg/kg IV bolus, then continuous infusion at 1 mg/kg/min 1, 6
  • Titrate upward by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min 1
  • 80% overall success rate with 30% hypotension risk 1
  • Load with a long-acting anticonvulsant (phenytoin, valproate, levetiracetam, or phenobarbital) during the midazolam infusion to ensure adequate levels before tapering 1

Alternative Anesthetic Agents:

• Propofol: 2 mg/kg bolus, then 3-7 mg/kg/hour infusion 1, 6

  • 73% seizure control rate with 42% hypotension risk 1
  • Requires mechanical ventilation but shorter ventilation time (4 days vs 14 days with pentobarbital) 1
  • Continuous blood pressure monitoring mandatory as hypotension occurs in 42% of patients 1

• Pentobarbital: 13 mg/kg bolus, then 2-3 mg/kg/hour infusion 1, 6

  • Highest efficacy at 92% seizure control but 77% hypotension risk 1
  • Use when other agents fail despite higher cardiovascular toxicity 1

EEG-Guided Titration

• Titrate anesthetic agents to achieve burst suppression pattern on EEG for at least 24 hours 1
• EEG monitoring is essential for detecting ongoing electrical seizure activity without motor manifestations 1

Super-Refractory Status Epilepticus (>24 hours despite anesthetic agents)

• Ketamine: 0.15-0.20 mg/kg IV bolus, then 1-5 mg/kg/hour continuous infusion 6
  • Start maintenance at 1 mg/kg/hour, titrate upward by 1 mg/kg/hour every 15 minutes based on EEG response 6
  • Unique hemodynamic advantage: 85% of patients requiring vasopressors can be weaned during ketamine infusion 6

Simultaneous Evaluation for Reversible Causes

While administering treatment, immediately search for and correct:

• Hypoglycemia (check fingerstick glucose) 1
• Hyponatremia 1
• Hypoxia 1
• Drug toxicity or withdrawal syndromes 1
• CNS infection 1
• Ischemic stroke or intracerebral hemorrhage 1

Critical Pitfalls to Avoid

• Never use neuromuscular blockers (e.g., rocuronium) alone — they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 1
• Do not skip directly to third-line agents (pentobarbital) until benzodiazepines and a second-line agent have been tried 1
• Do not delay respiratory support — equipment for airway management and mechanical ventilation must be immediately available before administering any agent 1, 2
• Avoid premature ambulation in elderly patients — those over 50 years may have more profound and prolonged sedation requiring 24-48 hours of observation 2

Key Safety Considerations

• Respiratory depression risk increases significantly when combining lorazepam with other sedative agents 4
• Valproate causes significantly less hypotension than phenytoin (0% vs 12%) while maintaining similar efficacy 1
• All anesthetic agents require mechanical ventilation support — have intubation equipment ready before administration 1