What is the management approach for a patient with status epilepticus in a prehospital setting, considering their airway, breathing, and circulation (ABCs) and potential history of epilepsy?

Prehospital Management of Status Epilepticus

In the prehospital setting, immediately secure the airway and administer IV lorazepam 4 mg at 2 mg/min (or 0.1 mg/kg) as first-line treatment, with a second dose after 5-10 minutes if seizures persist, while simultaneously checking blood glucose and preparing for rapid transport to the emergency department. 1, 2, 3

Immediate Stabilization (First 0-5 Minutes)

Airway, Breathing, and Circulation (ABC) Assessment:

• Assess and secure the airway immediately, as airway obstruction may occur in heavily sedated patients 2, 3
• Administer high-flow oxygen to prevent hypoxia, which worsens seizures 2
• Position patient to maintain airway patency and prevent aspiration 2
• Have ventilatory support equipment immediately available, as respiratory depression is the most important risk with benzodiazepine administration 3

Critical Initial Actions:

• Establish IV access for medication administration 2, 3
• Check fingerstick blood glucose immediately to rule out hypoglycemia as a reversible cause 2, 3
• Obtain vital signs including temperature to identify potential infectious causes 2
• Monitor continuous vital signs, oxygen saturation, ECG, and blood pressure 1

First-Line Pharmacologic Treatment (5-10 Minutes)

Benzodiazepine Administration:

• Administer lorazepam 4 mg IV at 2 mg/min (or 0.1 mg/kg, maximum 4 mg) as the primary first-line agent 1, 3
• Lorazepam demonstrates 65% efficacy in terminating status epilepticus and is superior to diazepam (65% vs 42.6% seizure termination rates) 1
• If IV access is not available, intramuscular lorazepam can be used, though therapeutic levels are reached more slowly than IV administration 3
• Alternative routes include intranasal or rectal benzodiazepines if IV/IM access is delayed 4

Critical Monitoring During Administration:

• Inject slowly with repeated aspiration to ensure proper IV placement 3
• Stop injection immediately if patient complains of pain, as this may indicate intra-arterial injection or perivascular extravasation 3
• Monitor closely for respiratory depression and be prepared to provide ventilatory support 3

Second Dose and Transport Decision (10-15 Minutes)

If Seizures Continue:

• Administer a second dose of lorazepam 4 mg IV slowly after a 10-15 minute observation period if seizures persist or recur 3
• Experience with further doses beyond two is very limited 3
• Initiate immediate transport to the emergency department, as prehospital recognition of status epilepticus was missed in 43.2% of cases in one study, leading to worse outcomes 5

Common Pitfalls in Prehospital Setting:

• Underdosing is extremely common: lorazepam was underdosed in 88.9% of prehospital cases and midazolam in 97.8% of cases 5
• Status epilepticus was not recognized in 48% of non-convulsive cases in the prehospital setting 5
• Patients with unrecognized status epilepticus were more likely to be discharged with new neurological deficits 5
• Only 6.7% of patients with known epilepsy received appropriate benzodiazepine dosing from bystanders before EMS arrival 5

Preparation for Hospital Transfer

During Transport:

• Maintain continuous monitoring of airway, breathing, and vital signs 2
• Keep patient positioned to protect airway 2
• Have suction and bag-valve-mask readily available 2
• Alert receiving facility about status epilepticus diagnosis and treatments administered 2

Documentation for Hospital Team:

• Time of seizure onset 2
• Medications administered with exact doses and times 2
• Blood glucose level 2
• Any known history of epilepsy or recent medication changes 2

Special Considerations

Risk Factors Requiring Extra Vigilance:

• Patients over 50 years may have more profound and prolonged sedation with lorazepam 3
• The sedative effects of lorazepam may add to post-ictal impairment of consciousness, especially with multiple doses 3
• Concomitant use with opioids may result in profound sedation and respiratory depression 3

Underlying Causes to Consider:

• Status epilepticus may result from correctable acute causes including hypoglycemia, hyponatremia, or other metabolic/toxic derangements that must be immediately sought and corrected 3
• CNS infection, stroke, or hemorrhage should be considered as potential etiologies 6

Key Safety Points:

• Equipment necessary to maintain a patent airway and support respiration/ventilation must be immediately available prior to IV lorazepam administration 3
• Airway patency must be assured and respiration monitored closely throughout treatment 3
• Ventilatory support should be given as required 3