What is the treatment for status epilepticus (seizure lasting more than 5 minutes or 2 or more seizures between which the patient doesn't return to baseline)?

Treatment of Status Epilepticus

Immediately administer intravenous lorazepam 4 mg at 2 mg/min (or 0.1 mg/kg) as first-line treatment, followed by a second-line anticonvulsant agent if seizures persist after 5-10 minutes. 1, 2, 3

Immediate First-Line Treatment: Benzodiazepines

• Lorazepam 4 mg IV at 2 mg/min is the preferred initial agent, with 64.9% efficacy in terminating overt generalized convulsive status epilepticus 3, 2
• If seizures continue after 10-15 minutes, administer a second dose of lorazepam 4 mg IV 2
• Alternative routes when IV access unavailable: IM midazolam 0.2 mg/kg (maximum 6 mg) or intranasal midazolam 1, 4
• Have airway equipment immediately available before administering any benzodiazepine, as respiratory depression can occur 1, 2

Critical concurrent action: Check fingerstick glucose immediately and correct hypoglycemia while administering benzodiazepines 1

Second-Line Treatment (If Seizures Persist After Benzodiazepines)

Administer ONE of the following second-line agents immediately - do not delay for neuroimaging 1:

Preferred Second-Line Options:

• Valproate 20-30 mg/kg IV over 5-20 minutes: 88% efficacy with 0% hypotension risk - superior safety profile compared to phenytoin 1
• Levetiracetam 30 mg/kg IV over 5 minutes: 68-73% efficacy with minimal cardiovascular effects, no cardiac monitoring required 1
• Fosphenytoin 20 mg PE/kg IV at maximum rate of 150 PE/min: 84% efficacy but 12% hypotension risk requiring continuous ECG and blood pressure monitoring 1
• Phenobarbital 20 mg/kg IV over 10 minutes: 58.2% efficacy but higher risk of respiratory depression 1

Valproate appears to be the optimal second-line choice due to superior safety profile (no hypotension) while maintaining equivalent efficacy to fosphenytoin 1

Refractory Status Epilepticus (Seizures Continuing Despite Benzodiazepines + One Second-Line Agent)

Initiate continuous EEG monitoring at this stage and proceed to anesthetic agents 1:

Third-Line Anesthetic Agents:

• Midazolam infusion (first choice for refractory SE):

  • Loading dose: 0.15-0.20 mg/kg IV 1, 4
  • Continuous infusion: Start at 1 mg/kg/min, titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min 1, 4
  • 80% overall success rate with 30% hypotension risk 1

• Propofol (requires mechanical ventilation):

  • 2 mg/kg bolus, then 3-7 mg/kg/hour infusion 1
  • 73% efficacy with 42% hypotension risk 1
  • Shorter ventilation time (4 days vs 14 days with pentobarbital) 1

• Pentobarbital (most effective but highest risk):

  • 13 mg/kg bolus, then 2-3 mg/kg/hour infusion 1
  • 92% efficacy but 77% hypotension requiring vasopressors 1

Essential Concurrent Management Throughout Treatment

Simultaneously search for and treat reversible causes 1:

• Hypoglycemia (check fingerstick glucose immediately)
• Hyponatremia and other electrolyte abnormalities
• Hypoxia (maintain airway, provide oxygen)
• Drug toxicity or withdrawal syndromes
• CNS infection (meningitis, encephalitis)
• Ischemic stroke or intracerebral hemorrhage
• Metabolic derangements

Critical Monitoring Requirements

• Continuous vital sign monitoring, particularly respiratory status and blood pressure 1, 4
• Prepare for mechanical ventilation before initiating any anesthetic agent 1
• Continuous EEG monitoring for refractory cases to guide titration and detect non-convulsive seizure activity 1

Common Pitfalls to Avoid

• Never use neuromuscular blockers alone (e.g., rocuronium) - they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 1
• Do not skip to third-line agents until benzodiazepines and at least one second-line agent have been tried 1
• Do not delay anticonvulsant administration for neuroimaging - CT scanning can be performed after seizure control is achieved 1
• Nothing should be put in the mouth and no oral medications should be given during active seizures 5
• Do not restrain the patient - instead, help them to the ground, place in recovery position, and clear the area 5

Activation of Emergency Medical Services

Activate EMS immediately for 5:

• First-time seizure
• Seizures lasting >5 minutes
• Multiple seizures without return to baseline between episodes
• Seizures in water, with traumatic injuries, difficulty breathing, or choking
• Seizure in infant <6 months or pregnant individuals
• Patient not returning to baseline within 5-10 minutes after seizure stops