Status epilepticus

Definition:
  1. continuous seizure activity lasting over 5 minutes
OR
  1. or when two or more seizures occur without full recovery of consciousness between them.
 

Treatments

After addressing airway, breathing, circulation

First Line

IV Lorazepam (Ativan) 0.1 mg/kg (max 4 mg/dose); may repeat once after 5 min
(preferred due to longer CNS half-life)
If no IV access:
  • IM Midazolam 10 mg (preferred prehospital choice)
  • or Rectal Diazepam 0.2–0.5 mg/kg (max 20 mg)

    Second-line

    Long-acting anti-seizure drug to prevent recurrence
    Pick one (IV preferred):
    Drug
    Adult Dose
    Notes
    Levetiracetam
    60 mg/kg IV (max 4500 mg)
    Low interaction, well tolerated
    Fosphenytoin
    20 mg PE/kg IV (max 1500 mg PE)
    Infuse ≤150 mg PE/min; monitor ECG/BP
    Valproate sodium
    40 mg/kg IV (max 3000 mg)
    Avoid in liver disease or pregnancy
    Phenobarbital
    15–20 mg/kg IV
    Use if others contraindicated
    (Levetiracetam or valproate often preferred over phenytoin for fewer adverse effects.)

    Refractory Status Epilepticus

    • Start continuous anesthetic infusion:
      • Midazolam: 0.2 mg/kg bolus → 0.05–2 mg/kg/hr infusion
      • Propofol: 1–2 mg/kg bolus → 2–10 mg/kg/hr infusion
      • Pentobarbital: 5–15 mg/kg bolus → 0.5–5 mg/kg/hr infusion
      • ketamine infusion
    • Continuous EEG monitoring to ensure seizure suppression (burst-suppression pattern).
     
    Other therapies:
    • hypothermia, immnosuppression, and inhaled anesthetic agents.