What are the specific drug doses and frequencies for the management of status epilepticus?

Status Epilepticus: Evaluation and Management Protocol

Immediate First-Line Treatment (0-5 minutes)

Administer IV lorazepam 4 mg at 2 mg/min immediately for adults (0.1 mg/kg for pediatrics, maximum 2 mg per dose) - this is the single most effective initial intervention with 65% efficacy in terminating status epilepticus. 1, 2, 3

Critical Simultaneous Actions

• Ensure airway equipment is immediately available before administering lorazepam, as respiratory depression can occur 1, 2
• Check fingerstick glucose immediately and correct hypoglycemia 1, 2
• Establish IV access, monitor vital signs continuously, and have artificial ventilation equipment ready 2
• Begin searching for reversible causes: hypoglycemia, hyponatremia, hypoxia, drug toxicity, CNS infection, stroke, intracerebral hemorrhage, and withdrawal syndromes 1, 2

Lorazepam Dosing Specifics

• Adults: 4 mg IV at 2 mg/min; may repeat once after 10-15 minutes if seizures continue 2
• Pediatric (convulsive): 0.1 mg/kg IV (maximum 2 mg), repeat after at least 1 minute up to maximum 2 doses 4, 5
• Pediatric (non-convulsive): 0.05 mg/kg IV (maximum 1 mg), repeat every 5 minutes up to maximum 4 doses 4, 5

Alternative if No IV Access

• IM midazolam 0.2 mg/kg (maximum 6 mg) is superior to IV lorazepam in prehospital settings with 73.4% seizure cessation 6

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Second-Line Treatment (5-20 minutes)

If seizures persist after adequate benzodiazepine dosing, immediately administer valproate 20-30 mg/kg IV over 5-20 minutes - this offers the best safety profile with 88% efficacy and 0% hypotension risk. 1

Second-Line Agent Options (Choose One)

Valproate (Preferred for safety profile):

• Dose: 20-30 mg/kg IV over 5-20 minutes 1
• Efficacy: 88% with 0% hypotension risk 1
• Advantage: Significantly less hypotension than phenytoin while maintaining similar efficacy 1

Levetiracetam (Excellent alternative):

• Dose: 30 mg/kg IV over 5 minutes (approximately 2000-3000 mg for average adults) 1
• Efficacy: 68-73% with minimal cardiovascular effects 1
• Advantage: No cardiac monitoring required, safe in elderly 1

Fosphenytoin/Phenytoin (Traditional agent):

• Dose: 20 mg PE/kg IV at maximum rate of 50 mg/min 1, 7
• Efficacy: 84% but 12% hypotension risk 1
• Critical: Requires continuous ECG and blood pressure monitoring 1, 7
• Pediatric rate: Not exceeding 1-3 mg/kg/min or 50 mg/min, whichever is slower 4

Phenobarbital:

• Dose: 20 mg/kg IV over 10 minutes (maximum 1000 mg) 4, 1
• Efficacy: 58.2% but higher risk of respiratory depression 1

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Refractory Status Epilepticus (>20-40 minutes)

Transfer to ICU immediately and initiate midazolam infusion as first-choice anesthetic agent - it offers 80% efficacy with only 30% hypotension risk compared to 77% with pentobarbital. 1

Midazolam Protocol

• Loading dose: 0.15-0.20 mg/kg IV 4, 1
• Continuous infusion: Start at 1 mg/kg/min 4, 1
• Titration: Increase by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min until seizures stop 4, 1
• Monitoring: Continuous EEG to guide titration and detect subclinical seizures 1

Alternative Anesthetic Agents

Propofol (if midazolam fails):

• Bolus: 2 mg/kg 1
• Infusion: 3-7 mg/kg/hour 1
• Efficacy: 73% seizure control 1
• Advantage: Requires fewer mechanical ventilation days (4 days vs 14 days with pentobarbital) 1
• Critical: Requires mechanical ventilation; monitor for hypotension (42% incidence) 1

Pentobarbital (most effective but highest risk):

• Bolus: 13 mg/kg 1
• Infusion: 2-3 mg/kg/hour 1
• Efficacy: 92% (highest) but 77% hypotension risk requiring vasopressors 1, 6

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Maintenance Dosing After Seizure Control

Adults

• Lorazepam: Not typically continued as maintenance 2
• Levetiracetam: 30 mg/kg IV every 12 hours OR increase prophylaxis dose by 10 mg/kg (to 20 mg/kg) IV every 12 hours (maximum 1500 mg) 4, 1
• Phenobarbital: 1-3 mg/kg IV every 12 hours 4

Pediatrics (Convulsive Status Epilepticus)

• Lorazepam: 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 4
• Levetiracetam: 30 mg/kg IV every 12 hours (maximum 1500 mg) 4
• Phenobarbital: 1-3 mg/kg IV every 12 hours 4

Pediatrics (Non-Convulsive Status Epilepticus)

• Lorazepam: 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 4
• Levetiracetam: 15 mg/kg (maximum 1500 mg) IV every 12 hours 4
• Phenobarbital: 1-3 mg/kg IV every 12 hours 4

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Critical Monitoring Requirements

For All Patients

• Continuous vital sign monitoring, particularly respiratory status and blood pressure 1
• Oxygen saturation monitoring with supplemental oxygen available 4
• Airway equipment and artificial ventilation immediately available 2

For Refractory Status Epilepticus

• Continuous EEG monitoring to detect ongoing electrical seizure activity without motor manifestations 1
• Prepare for mechanical ventilation when using anesthetic agents 1

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Common Pitfalls to Avoid

Never use neuromuscular blockers (like rocuronium) alone - they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 1

Do not skip to third-line agents (pentobarbital) until benzodiazepines and a 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

Avoid combining lorazepam with other sedatives without preparation for respiratory support - this significantly increases apnea risk 4, 5

Do not use phenytoin with glucose-containing solutions - this causes precipitation 6

Monitor for Lance-Adams syndrome (generalized myoclonus with epileptiform discharges) after prolonged status epilepticus - this may be compatible with good outcome and should not be treated overly aggressively 1