Status Epilepticus: Immediate Treatment Protocol
Administer IV lorazepam 4 mg at 2 mg/min immediately as first-line treatment, followed by a second-line agent (fosphenytoin, valproate, or levetiracetam) if seizures persist after 10-15 minutes, and escalate to anesthetic agents (midazolam, propofol, or pentobarbital) for refractory cases. 1, 2, 3
Immediate Actions (First 5 Minutes)
Before administering any medication:
- Ensure airway equipment is immediately available—bag-valve-mask, intubation supplies, and suction 3
- Establish IV access and start fluid resuscitation 2
- Check fingerstick glucose immediately and correct hypoglycemia with IV dextrose 1, 2
- Monitor continuous vital signs, oxygen saturation, ECG, and blood pressure 2
First-Line Treatment: Benzodiazepines
Lorazepam 4 mg IV at 2 mg/min is the strongest evidence-based first-line agent with 65% efficacy in terminating status epilepticus 1, 3. If seizures continue after 10-15 minutes, administer a second 4 mg dose slowly 3. Lorazepam is superior to diazepam (59.1% vs 42.6% seizure termination) 1.
Critical safety measure: Have ventilatory support ready before administration, as respiratory depression is the most important risk 3.
Alternative routes if IV access unavailable:
Second-Line Treatment (If Seizures Persist After Benzodiazepines)
Select ONE of the following agents immediately—do not delay for neuroimaging: 1, 2
Valproate (Preferred for Safety Profile)
- Dose: 30 mg/kg IV over 5-20 minutes (approximately 2000-2500 mg for average adult) 1, 2, 4
- Efficacy: 88% seizure control 1, 2
- Hypotension risk: 0% (significantly safer than phenytoin) 1, 2
- Advantage: Can be administered rapidly without cardiac monitoring 2
- Contraindication: Avoid in women of childbearing potential due to teratogenicity 2
Fosphenytoin (Most Widely Available)
- Dose: 20 mg PE/kg IV at maximum rate of 150 PE/min 1, 2
- Efficacy: 84% seizure control 1, 2
- Hypotension risk: 12% 1, 2
- Requirement: Continuous ECG and blood pressure monitoring mandatory 2, 4
- Note: 95% of neurologists recommend phenytoin/fosphenytoin for benzodiazepine-refractory seizures 2
Levetiracetam (Best Cardiovascular Safety)
- Dose: 30 mg/kg IV over 5 minutes (approximately 2000-3000 mg for average adult) 1, 2
- Efficacy: 68-73% seizure control 1, 2
- Hypotension risk: Minimal, no cardiac monitoring required 1, 2
- Advantage: Safe in elderly patients and those with cardiac disease 1
Phenobarbital (Alternative Option)
- Dose: 20 mg/kg IV over 10 minutes (maximum 1000 mg) 1, 2
- Efficacy: 58.2% as initial second-line agent 1, 2
- Risk: Higher respiratory depression and hypotension 2
Refractory Status Epilepticus (Seizures Continue After Second-Line Agent)
Definition: Seizures persisting despite benzodiazepines and one second-line agent 2. Initiate continuous EEG monitoring at this stage 2.
Escalate to anesthetic agents—select ONE: 1, 2
Midazolam Infusion (First-Choice Anesthetic)
- Loading dose: 0.15-0.20 mg/kg IV 1, 2
- Continuous infusion: 1 mg/kg/min, titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min 1, 2
- Efficacy: 80% overall success rate 1, 2
- Hypotension risk: 30% (lowest among anesthetics) 1, 2
- Advantage: Better hemodynamic profile than barbiturates 2
Propofol (For Intubated Patients)
- Loading dose: 2 mg/kg bolus 1, 2
- Continuous infusion: 3-7 mg/kg/hour 1, 2
- Efficacy: 73% seizure control 1, 2
- Hypotension risk: 42% 1, 2
- Advantage: Shorter mechanical ventilation time (4 days vs 14 days with barbiturates) 1, 2
- Requirement: Mechanical ventilation mandatory 2
Pentobarbital (Highest Efficacy, Most Side Effects)
- Loading dose: 13 mg/kg 1, 2
- Continuous infusion: 2-3 mg/kg/hour 1, 2
- Efficacy: 92% seizure control (highest) 1, 2
- Hypotension risk: 77% (requires vasopressors) 1, 2
- Disadvantage: Prolonged mechanical ventilation (mean 14 days) 1, 2
Simultaneous Evaluation for Reversible Causes
Search for and correct these immediately while administering anticonvulsants: 1, 2, 4
- Hypoglycemia (check fingerstick glucose first) 1, 2
- Hyponatremia 1, 2, 4
- Hypoxia 1, 2, 4
- Drug toxicity or withdrawal syndromes 1, 2, 4
- CNS infection (meningitis, encephalitis) 1, 2, 4
- Ischemic stroke 1, 2
- Intracerebral hemorrhage 1, 2
Critical Monitoring Requirements
For all anesthetic agents: 1, 2
- Continuous EEG monitoring to guide titration and detect ongoing electrical seizure activity 1, 2
- Continuous blood pressure monitoring 2
- Mechanical ventilation readiness 2
- Vasopressor availability (norepinephrine or phenylephrine) 2
Common Pitfalls to Avoid
Never use neuromuscular blockers (rocuronium) alone—they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 2.
Do not skip to third-line agents (pentobarbital) until benzodiazepines and a second-line agent have been tried 2.
Do not delay anticonvulsant administration for neuroimaging—CT scanning can be performed after seizure control is achieved 1.
Do not underdose second-line agents—use full weight-based dosing (30 mg/kg for levetiracetam and valproate, 20 mg PE/kg for fosphenytoin) 1, 2.
Maintenance Therapy During Anesthetic Infusion
Load with long-acting anticonvulsant during midazolam/propofol infusion to ensure adequate levels before tapering anesthetic 2:
- Continue phenytoin/fosphenytoin, valproate, or levetiracetam 2
- Taper anesthetic after 12-24 hours of seizure control 2
- Maintain continuous EEG monitoring during withdrawal 2
Super-Refractory Status Epilepticus
If seizures persist despite anesthetic agents, consider ketamine as fourth-line agent 2:
- Efficacy: 64% when administered early (within 3 days), drops to 32% when delayed 2
- Mechanism: NMDA receptor antagonist, mechanistically distinct from GABA-ergic agents 2
- Dosing: 0.45-2.1 mg/kg/hour 2