Status Epilepticus

Definition: seizures lasting > 5 minutes or multiple seizures without return to baseline in between

ASAP

  1. Stabilize (Airway, Breathing, Circulation)

  2. Begin timer, monitor vital signs

  3. Assess oxygenation - provide supplemental O2 or consider intubation if necessary

  4. Initiate EKG monitoring

  5. Collect fingerstick glucose, if < 60 mg/dL

    • adults: given 100 mg thiamine IV, then 50 mL 50% dextrose (1 amp of D50) IV

    • children ≥ 2 years: 2 mL/kg 25% dextrose IV

  6. Attempt IV access and collect CBC, BMP, toxicology screen, anti-seizure medication levels (if relevant)

t = 5 Minutes (impending status)

**it is OK to treat prior to 5 min**

  • First-line = Benzodiazepine, choice of

    1. Lorazepam (Ativan) IV 0.1 mg/kg/dose, max 4 mg/dose

      • may repeat dose once

    2. Diazepam (Valium) IV 0.2 mg/kg/dose, max 10 mg/dose

      • or per rectum 0.2-0.5 mg/kg/dose, max 20 mg/dose

      • may repeat dose once

    3. Midazolam (Versed) IV or IM

      • 10 mg for pt weight > 40 kg

      • 5 mg for pt weight 13-40 kg

      • do not repeat dose

t = 20 minutes (established status)

  • Second-line medications

  • Send free and total medication levels 1 hour after completing dose

    1. Levetiracetam (Keppra) IV 60 mg/kg, max 4500 mg/dose

      • loading dose does not require renal adjustment

    2. Valproic Acid (Depakote) IV 40 mg/kg, max 3000 mg/dose

      • excellent option if patient is hypotensive

      • caution in liver disease or women who may be pregnant

      • repeat 20 mg/kg bolus if seizures continue

    3. Fosphenytoin (Cerebryx) IV 20 mg PE/kg, max 1500 mg/dose

      • requires BP and EKG monitoring - decrease infusion rate if hypotensive

      • may administer IM if no IV access

      • repeat 10 mg PE/kg if seizures continue

  • Alternative Options:

    1. Lacosamide (Vimpat) IV 400 mg

    2. Phenytoin (Dilantin) IV 20 mg/kg

      • avoid if fosphenytoin is available as phenytoin results in hypotension and can cause tissue necrosis (purple glove syndrome)

t = 40 minutes (refractory status)

Intubate if not already done

  • AVOID depolarizing neuromuscular blockade (e.g. succinylcholine)

Connect EEG if not already done

  • Choice of

    1. Midazolam (Versed) 0.2 mg/kg bolus followed by 0.1 mg/kg/hr infusion

    2. Propofol 5-80 mcg/kg/min

      • Avoid bolus unless you are prepared to correct hypotension with pressors

      • several status algorithms allow higher dosing (up to 400 mcg/kg/min)

    3. Phenobarbital/Pentobarbital 10-20 mg/kg bolus followed by 0.5 mg/kg/hr infusion

  • Drips should be titrated either to seizure-suppression or burst-suppression, guided by EEG monitoring