Status epilepticus

Background

Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments.^[1]^[2] (Previous definitions used a 30-minute time limit)^[3]
Overall mortality is high (22%)^[4]

Protect patient from injury
- If possible, place patient in left lateral position to reduce risk of aspiration
- Do not place bite block!
Benzodiazepine (Initial treatment of choice)^[7]
- Midazolam IM 10mg (>40kg), 5mg (13-40kg), or 0.2mg/kg^[8] - may also be given IN
- Lorazepam IV 2mg or 0.1mg/kg
- Diazepam IV 0.15-0.2mg/kg (up to 10mg) or PR 0.2-0.5mg/kg (up to 20mg)
Secondary medications
- Fosphenytoin IV 20-30mg/kg at 150mg/min (may also be given IM)
  - Contraindicated in pts w/ 2nd or 3rd degree AV block
- Valproic acid IV 20-40mg/kg at 5mg/kg/min
- Levetiracetam IV 60mg/kg, max 4500mg/dose
- Phenobarbital IV 20mg/kg at 50-75mg/min (be prepared to intubate)
Refractory medications
- Propofol 2-5mg/kg, then infusion of 2-10mg/kg/hr OR
- Midazolam 0.2mg/kg, then infusion of 0.05-2mg/kg/hr OR
- Ketamine loading dose 0.5 to 3 mg/kg, followed by infusion of 0.3 to 4 mg/kg/hr^[9]
- Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)^[10]
Consider
- Secondary causes of seizure (e.g. hyponatremia, hypoglycemia, INH toxicity, ecclampsia)
- Nonconvulsive seizures or status epilepticus - get EEG

Admit to ICU or intermediate level of monitored care depending on etiology, treatments and respiratory status

↑ Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9
↑ Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8
↑ Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.
↑ Martindale JL, Goldstein JN, Pallin DJ. Emergency department seizure epidemiology. Emerg Med Clin North Am. 2011 Feb;29(1):15-27.
↑ Brodie MJ. Status epilepticus in adults. Lancet. 1990 Sep 1; 336(8714):551-2.
↑ Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med. 1998; 338:970-976
↑ Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016; 16(1):48-61.
↑ McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582
↑ Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
↑ Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.