Status Epilepticus

First Line:  Lorazepam or Midazolam – 2mg IV q2mins x 5 doses (10mg total)

Second Line:  Phenytoin / fosphenytoin – 20-30 mg/Kg IV

Third Line:  Phenobarbital 20-30mg/Kg IV or Levetiracetam 1.5-2g IV or Valproic Acid 20mg/Kg (max 45 mg/Kg)

0.2-0.3 mg/Kg bolus IV then 0.05-2mg/Kg/hr
Propofol: 2-5 mg/Kg bolus IV then 20-100 ug/Kg/min
Pentobarbital: 5-15 mg/Kg IV then 0.5-10 mg/Kg/hr

STESS: Status Epilepticus Severity Score

  0 1 2 3
Seizure type Simple or complex partial, absence Generalized convulsive seizures NCSE in coma
History of seizures History of seizures No history of seizures
Age >/=65 <65
LOC at SE onset Awake or somnolent Stuporous or comatose

Best match for Sn (0.67) and Sp (0.75) with cutoff >/=4(Sutter, Raoul Crit Care Med Dec 2013 Vol 41 No 12), original score cutoff >/=3.


Reference: The Lancet Neurology Volume 5, Issue 3, March 2006, Pages 246–256

Impending or established status epilepticus: start with 20 mg/kg of fosphenytoin or phenytoin, and if status epilepticus persists, give an additional 10 mg/kg.
Follow the flow chart
UNLESS there is a history of drug intolerance (eg, allergy to phenytoin or benzodiazepine) then replace by intravenous (IV) valproic acid 40–60 mg/kg or IV phenobarbital 20 mg/kg;
UNLESS treatment-induced hypotension slows rate of delivery;
UNLESS history of progressive (PME) or juvenile (JME) myoclonus epilepsy (phenytoin/fosphenytoin harmful in PME, ineffective in JME), replace with IV valproic acid or IV phenobarbital;
UNLESS tonic status epilepticus with Lennox- Gastaut syndrome (might be worsened by benzodiazepines), replace with IV valproic acid or IV phenobarbital;
UNLESS, acute intermittent porphyria, avoid P450 inducers, replace by NG gabapentin (if possible) or by IV valproic acid;
UNLESS, focal status epilepticus without impairment of consciousness, IV treatment not indicated, load anticonvulsants orally or rectally.

Refractory status epilepticus: IV valproic acid-start with 40 mg/kg and, if status epilepticus persists, give an additional 20 mg/kg. Continous intravenous infusion (CIV) usually starts with the lower dose, which is titrated to achieve seizure suppression and is increased as tolerated if tachyphylaxis develops.

Ketamine: rule out increased intracranial pressure before administration.

Other drugs: felbamate, topiramate, levetiracetam, lidocaine, inhalation anaesthetics, etc.


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