Clinical Neurology · Epilepsy & EEG
Status Epilepticus
A stepwise protocol for the management of status epilepticus, organized by treatment line and time-based stages.
Definitions
- Status: Continuous seizure activity > 5 minutes or recurrent seizures without full recovery
- Refractory Status: Status refractory to 1st and 2nd line treatment, requiring sedation
- Super Refractory Status: Status recurs after withdrawal of 3rd line (sedation)
Stabilize
- ABC’s
- Finger stick blood glucose
- Get an IV access
1st Line
- Lorazepam 4mg IV (0.1mg/kg)
- No IV access: Midazolam 10mg IM (0.2mg/kg)
- Repeat One More Time If Needed
2nd Line — Loading with AED
- Levetiracetam 60 mg/kg (max 4500mg)
- Valproic acid 40 mg/kg (max 3000mg)
- Fosphenytoin 20 mg/kg (max 1500mg)
- Lacosamide 400 mg (needs EKG before and after)
After 2nd Line
Seizures Controlled → Start on Maintenance
- Levetiracetam 1:2 gm Bid
- Valproic acid 5:10 mg/kg q8h
- Fosphenytoin 5:7 mg/kg q8h
- Lacosamide 100:200 mg bid
Seizures Continue → Prepare for 3rd Line
- Intubation
- Mechanical Ventilation
3rd Line — Continuous Sedation
| Drug | Loading | Maintenance | Titration till Burst Suppression |
|---|---|---|---|
| Propofol | 1 mg/kg | Start 40, Max 200 mcg/kg/min | 20 mcg/kg/min q5min |
| Midazolam | 10 mg (0.2mg/kg) | Start 0.05, Max 2 mg/kg/h | 0.1 mg/kg/h q15min |
| Ketamine | 1:2 mg/kg | Start 0.3, Max 2 mg/kg/h | 0.3 mg/kg/h q15min |
Continuous EEG
- Target: Burst Suppression for at least 24 hours
- Then: Taper sedation over 24 hours
- Optimize Maintenance AED before taper
- Ensure high therapeutic AED level before down titration
- Tapering rate: one medication at a time, down by 25% q6h
Other Lines of Treatment
- Pentobarbital: Load with 5mg/kg then infusion at 1:10 mg/kg/h
- IVIG or Pulse Steroids: if autoimmune etiology is suspected
- Magnesium 4gm then 2gm q6h, specially in eclampsia
Prognosis
Mortality rate:
- Status: 10:30%
- Refractory Status: 30:50%
- Super Refractory Status: >50%
- Worse prognosis: Post-anoxic – old age
Ahmed Koriesh, MD