What is the initial management of a patient presenting with status epilepticus?

Initial Management of Status Epilepticus

Immediately administer IV lorazepam 4 mg at 2 mg/min as first-line treatment, followed by a second-line antiseizure medication (fosphenytoin, valproate, or levetiracetam) if seizures continue after 5-10 minutes. 1, 2

Immediate Stabilization (0-5 Minutes)

Airway and Vital Support

• Assess and secure airway, breathing, and circulation (CAB) immediately 1
• Administer high-flow oxygen to prevent hypoxia, which worsens seizures 1
• Have airway equipment and bag-valve-mask immediately available before administering any medication, as respiratory depression is common 1, 2
• Establish IV access urgently for medication administration 1

Critical Initial Assessment

• Check fingerstick glucose immediately to rule out hypoglycemia as a reversible cause 1
• Obtain vital signs including temperature to identify infectious causes 1
• Do NOT restrain the patient or put anything in their mouth during active seizure 3

First-Line Treatment: Benzodiazepines

• Administer lorazepam 0.1 mg/kg IV (maximum 4 mg) at 2 mg/min 1, 2
• Lorazepam is superior to diazepam (65% vs 56% efficacy) with longer duration of action 3
• May repeat once after 5-10 minutes if seizures continue 1, 2
• Alternative if IV access unavailable: IM midazolam 0.2 mg/kg (maximum 6 mg) 3

Second-Line Treatment (5-20 Minutes)

If seizures persist after adequate benzodiazepine dosing, immediately administer ONE of the following agents 1, 4:

Preferred Second-Line Options (Choose One)

Valproate is the optimal choice for most patients:

• Dose: 30 mg/kg IV over 5-20 minutes 4, 3
• 88% efficacy with 0% hypotension risk 4, 3
• Superior safety profile compared to phenytoin 3
• Contraindication: Women of childbearing potential (high teratogenicity risk) 3

Levetiracetam is ideal for elderly or hemodynamically unstable patients:

• Dose: 30-40 mg/kg IV (maximum 2,500-3,000 mg) over 5-15 minutes 1, 3
• 68-73% efficacy with minimal cardiovascular effects 1, 4
• No cardiac monitoring required 3
• Requires renal dose adjustment in kidney disease 3

Fosphenytoin is the traditional option:

• Dose: 20 mg PE/kg IV at maximum rate of 150 mg/min 1, 4
• 84% efficacy but 12% hypotension risk 4, 3
• Requires continuous ECG and blood pressure monitoring 3
• 95% of neurologists use this as second-line agent 3

Phenobarbital (alternative):

• Dose: 20 mg/kg IV over 10 minutes (maximum 1,000 mg) 1, 3
• 58.2% efficacy as initial second-line agent 4, 3
• Higher risk of respiratory depression and hypotension 5, 3

Critical Pitfall to Avoid

Never skip directly to third-line anesthetic agents (pentobarbital, propofol) until benzodiazepines AND a second-line agent have been tried 3

Refractory Status Epilepticus (20+ Minutes)

Status epilepticus continuing despite benzodiazepines and one second-line agent is defined as refractory and requires ICU transfer 1, 3

Third-Line Anesthetic Agents (Choose One)

Midazolam infusion (first choice for refractory SE):

• Loading dose: 0.15-0.20 mg/kg IV 1, 3
• Continuous infusion: 1 mg/kg/min, titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min 3
• 80% overall success rate with 30% hypotension risk 5, 3
• Lower hypotension risk than barbiturates 3

Propofol (alternative):

• Loading dose: 1-2 mg/kg IV bolus 1, 3
• Continuous infusion: 2-10 mg/kg/hour 1, 3
• 73% efficacy with 42% hypotension risk 5, 3
• Requires mechanical ventilation but shorter duration (4 days vs 14 days with barbiturates) 3

Pentobarbital (highest efficacy but most complications):

• Loading dose: 10-20 mg/kg IV at 50-100 mg/min 1
• Continuous infusion: 2-3 mg/kg/hour 3
• 92% efficacy but 77% hypotension requiring vasopressors 5, 3
• Prolonged mechanical ventilation (mean 14 days) 3

Essential Monitoring for Refractory SE

• Initiate continuous EEG monitoring immediately 1, 6
• Continuous blood pressure and cardiac monitoring 3
• Prepare for mechanical ventilation 1, 3
• Have vasopressors immediately available 3

Simultaneous Evaluation for Underlying Causes

While treating seizures, urgently search for and correct reversible causes 1, 3:

Laboratory Studies

• Electrolytes (hyponatremia, hypoglycemia) 1, 3
• Complete blood count 1
• Toxicology screen 1
• Anticonvulsant drug levels 1

Identify Specific Etiologies

• Hypoglycemia, hyponatremia, hypoxia 4, 3
• Drug toxicity or withdrawal syndromes 3
• CNS infection (meningitis, encephalitis) 4, 3
• Ischemic stroke or intracerebral hemorrhage 4, 3
• Autoimmune encephalitis (especially in NORSE/FIRES) 6, 7

Neuroimaging

• Obtain CT or MRI once patient is stabilized 1
• Do NOT delay anticonvulsant administration for imaging 3

Maintenance Therapy After Seizure Cessation

Continue maintenance doses of antiseizure medications 1:

• Levetiracetam: 30 mg/kg IV every 12 hours (maximum 1,500 mg) for convulsive SE 3
• Levetiracetam: 15 mg/kg IV every 12 hours (maximum 1,500 mg) for non-convulsive SE 3
• Phenobarbital: 1-3 mg/kg IV every 12 hours 1
• Valproate or phenytoin: appropriate maintenance doses 1

Critical Monitoring During Maintenance

• Monitor for respiratory depression, hypotension, and cardiac arrhythmias 1
• Continuous EEG for minimum 48 hours after anesthetic discontinuation, as nonconvulsive seizures occur in >50% of cases 3
• Do not attribute altered mental status solely to post-ictal state—obtain urgent EEG if patient does not awaken as expected 3

Key Clinical Pearls

Common pitfalls to avoid:

• Never use neuromuscular blockers alone (rocuronium)—they only mask motor manifestations while allowing continued brain injury 3
• Valproate causes significantly less hypotension than phenytoin (0% vs 12%) while maintaining similar efficacy 4, 3
• Mortality increases dramatically with refractoriness: 10% in responsive cases, 25% in refractory, 40% in super-refractory SE 6
• Status epilepticus is defined operationally as seizure lasting >5 minutes for treatment purposes, though classical definition is >20 minutes 3