Status Epilepticus

We initiate this treatment algorithm after five minutes of continuous generalized seizure activity.

• Oxygen
• ECG
• Fingerstick glucose.
• At the very least, treat for glucose less than 60 mg/dl.
• Remember to give thiamine 100 mg IV prior giving 50 ml of D50 IV in suspected alcoholics or patient's susceptible to Korsakoff syndrome.

Give any of the following (all of these are roughly equivalent in efficacy):

• Lorazepam, max 8 mg IV
• Diazepam, max 30 mg IV
• Midazolam, max 10 mg IM

If benzodiazepines aren't an option, give:

• Phenobarbital, max 15mg/kg IV

Give any of the following (all of these are roughly equivalent in efficacy):

• Levetiracetam, max 4,500 mg IV
• Fosphenytoin, max 1,500 PE IV (PE = phenytoin equivalents)
• fosphenytoin is preferred over phenytoin.
• Valproic acid, max 3,000 mg IV

Additional first or second phase medications. Be on the lookout for lacosamide 400 mg IV to be incorporated into this protocol in the future. Status epilepticus refers to seizure activity lasting longer than 30 minutes or recurrent seizures without intervening recovery. Note, however, that we do not wait 30 minutes for patients to develop status epilepticus, instead we initiate our status management at 5 minutes (as described below). First let's divide forms of status epilepticus into: Convulsive Status – Repeated generalized tonic-clonic seizures with post-ictal depression. Non-Convulsive Status – Continuous seizure activity with cognitive changes (aka "epileptic twighlight"). Repeated partial seizures – repeated focal seizures: repeated focal symptoms or signs. It's important to know that convulsive status is associated with a high probability of mortality. In children, on average, it is 3% whereas in adults it is, on average, 30%. However, this large depends on the underlying cause of the seizures, as well as the patient's age, and the duration of the status epilepticus. Because the underlying etiology for the seizures that is the major contributor to this poor prognosis, if there is no serious underlying morbidity, we should never "give-up" on a patient no matter how long the duration of the status epilepticus, as the seizures can persist for weeks and patients can still have a good outcome if the underlying etiology resolves or is treated.