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Status Epilepticus

Time-critical stepwise approach to convulsive status epilepticus

Overview

  • Time-critical stepwise approach to convulsive status epilepticus

Protocol steps

  • id: 1; title: Phase 1 — Stabilize (0-5 min); detail: ABCs, IV access, O2, fingerstick glucose. Place patient in recovery position if no IV. Begin seizure timer. Give benzodiazepine immediately.; time: 300; drugs: name: Lorazepam; dose: 0.1mg/kg IV (max 4mg); name: Midazolam; dose: 10mg IM if no IV access
  • id: 2; title: Phase 2 — Urgent AED (5-20 min); detail: If seizure continues after benzodiazepine, give second-line agent. May repeat benzodiazepine once while second-line loading. Order labs: BMP, CBC, glucose, AED levels, tox screen, lactate.; time: 900; drugs: name: Levetiracetam; dose: 60mg/kg IV (max 4500mg) over 15 min; name: Fosphenytoin; dose: 20mg PE/kg IV at max 150mg PE/min; name: Valproic Acid; dose: 40mg/kg IV (max 3000mg) over 10 min; branch: true
  • id: 3; title: Phase 3 — Refractory SE (20-40 min); detail: Seizure persists despite two adequate AED trials. Prepare for intubation. Give third-line agent. Contact neurology. Continuous EEG monitoring if available.; time: 1200; drugs: name: Phenobarbital; dose: 20mg/kg IV at max 60mg/min; branch: true
  • id: 4; title: Phase 4 — Super-Refractory SE (>40 min); detail: Intubation likely required. Initiate continuous infusion. Neurology and ICU consultation mandatory. Continuous EEG monitoring essential.; time: ; drugs: name: Propofol; dose: 1-2mg/kg IV bolus, then 20-200mcg/kg/min infusion; name: Midazolam; dose: 0.2mg/kg IV bolus, then 0.05-2mg/kg/hr infusion; name: Ketamine; dose: 1-3mg/kg IV bolus, then 0.5-10mg/kg/hr infusion; branch: true
  • id: 5; title: Consider Etiology; detail: Investigate and treat underlying cause: hypoglycemia (D50), hyponatremia (3% saline), INH toxicity (pyridoxine), eclampsia (magnesium), CNS infection (empiric antibiotics), structural lesion (CT/MRI).; time: ; drugs: name: Pyridoxine (B6); dose: 5g IV if INH suspected; name: Magnesium; dose: 4-6g IV over 20 min if eclampsia

Source and review

  • AES Status Epilepticus Guidelines 2016; Neurocritical Care Society. Last reviewed: 2024-11-01