How is status epilepticus (SE) treated in the emergency department (ED)?

Updated: Feb 13, 2018
  • Author: Julie L Roth, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Answer

Regardless of the clinical manifestations of generalized SE, aggressive supportive care and prompt termination of electrical seizure activity are the goals. Care is individualized to the patient.

Establish intravenous access, ideally in a large vein. Intravenous administration is the preferred route for anticonvulsant administration because it allows therapeutic levels to be attained more rapidly. Begin cardiac and other hemodynamic monitoring.

Administer a 50-mL bolus of 50% dextrose IV and 100 mg of thiamine. If seizure activity does not terminate within 4-5 minutes, start anticonvulsant medication. If EMS history has already defined SE, treatment should begin immediately. In some settings where drug intoxication might be likely, consider also adding naloxone at 0.4-2.0 mg IV to the dextrose bag.

Administer diazepam (0.15 mg/kg) or lorazepam (0.1 mg/kg) IV over 5 minutes, followed by fosphenytoin or phenytoin. Fosphenytoin is preferable, as it provides the advantage of a potentially rapid rate of administration with less risk of venous irritation (eg, to avoid the risk of purple-glove syndrome with phenytoin).

Fosphenytoin is given in a dose of 15-20 mg phenytoin equivalents [PE]/kg, at a rate not to exceed 150 mg PE/min). The dose of phenytoin is 18-20 mg/kg, at a rate not to exceed 50 mg/min). Never mix phenytoin with a 5% dextrose solution; put it in a normal saline solution to minimize the risk of crystal precipitation.

Ensure airway control. Nasopharyngeal airway placement is sufficient for some patients, particularly if the seizures are stopped and the patient is awakening. For other patients, endotracheal intubation is necessary. In neuromuscular paralysis, rapid sequence induction is necessary at times. Use short-acting paralytics to ensure that ongoing seizure activity is not masked. Use EEG monitoring if long-acting paralytics are used and if a question exists about seizure cessation.

Correct any metabolic imbalances. Control hyperthermia.

If seizures continue after 20 minutes, give additional fosphenytoin (10 mg PE/kg IV) or phenytoin (10 mg/kg IV). Aim for a total serum phenytoin level of about 22-25 µg/mL.

In patients with epilepsy partialis continua who had been receiving AED treatment, knowledge of the patient's usual regimen and current levels may be pivotal. As an alternative to fosphenytoin or phenytoin, supplementation of their routine medication (guided by stat AED levels) may help suppress their seizures.

Failure to respond to optimal benzodiazepine and phenytoin loading operationally defines refractory status epilepticus. If seizures continue after 20 minutes, give phenobarbital (15 mg/kg IV). Use caution when adding barbiturates to benzodiazepines because their coadministration may potentiate ventilatory failure. This may be especially true for patients (eg, elderly patients) with impaired drug clearance.

For this reason, especially in the setting of partially treated epilepsy partialis continua or simple partial SE, in which the morbidity of the underlying illness is less than in generalized convulsive SE, a tempered approach may be preferred. Incremental doses of phenobarbital may offer satisfactory efficacy in these uncommon settings and may be safer than full intravenous loading doses, which increase the risk of respiratory suppression.

Alternatives to phenobarbital that are shorter acting and allow for periodic neurologic assessments include the following [63, 64] :

  • Valproate

  • Levetiracetam

  • Propofol [65, 66]

  • Midazolam

  • Pentobarbital

  • Ketamine [67] }

If seizures continue, consider administering general anesthesia with medications such as propofol, midazolam, or pentobarbital. Ketamine infusion can alternatively (or additionally) be used in the treatment of refractory status epilepticus, with some evidence of safety and efficacy. These agents are given by IV drip and titrated to a burst-suppression pattern in the EEG trace. In a patient with epilepsy partialis continua or simple partial SE, one might even consider rapid oral loading of one of the newer AEDs (eg, topiramate [68] ), depending on the ongoing clinical urgency. Lacosamide is a novel antiepileptic drug available in IV form; though anecdotally it appears safe, its effectiveness in treatment of refractory SE is unknown.

If the patient promptly becomes alert after receiving a benzodiazepine or other AED, that tends to corroborate the diagnosis of SE. Nevertheless, the failure to become alert by no means excludes the diagnosis of SE. Most patients remain sleepy or stuporous after the resolution of a prolonged episode of SE, whether focal or generalized.

For this reason, bedside EEG assessment can be invaluable in guiding treatment decisions. This is true not only early in the treatment paradigm but also late to help gauge the patient's recovery and to ensure that he or she is not having repeated subclinical seizures. Portable computer-aided EEG monitoring (LTM system) can be particularly helpful in this task.


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