Status Epilepticus (SE)

Definition

  1. continuous seizure activity lasting over 5 minutes (boards says 30 minutes)
OR
  1. or when two or more seizures occur without full recovery of consciousness between them.

Types of SE

  • Convulsive SE: Tonic–clonic activity (most common, easiest to recognize).
  • Nonconvulsive SE: Persistent altered mental status or subtle motor signs with EEG seizure activity.
  • Focal SE: Continuous focal motor or sensory seizure without generalization.

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
Drug
Adult Dose
Notes
Fosphenytoin
15-20 mg mg/kg IV (max 1500 mg)
- Infuse ≤150 mg PE/min; monitor ECG/BP
- use first once benzos fail
Levetiracetam
60 mg/kg IV (max 4500 mg)
Low interaction, well tolerated
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.