0 - 5"

6-10"

10-20"

30-60"

References

Management of Status Epilepticus  

The following guidelines are intended as general guidelines, and may not be appropriate for all patients or in all circumstances. Compiled by Rosario Maria S. Riel-Romero, MD.

0 - 5"

• Diagnose status epilepticus

• Assess & control airway

• Oxygen by NC or mask

• Position patient’s head for optimal airway patency.

• Monitor VS ( BP, HR, RR, Temp, O2 sats) at outset and thereafter.

• Pulse ox or ABG

• Establish IV line. Start Plasmalyte or Normosol.

• Draw blood for: CBC diff plt, CMP, Ca,Mg, Phos, AED levels

• Urinalysis, Urine Drug Screen, Urine Pregnancy Test

• Administer lorazepam

  • Adults: 4 mg (at 2mg/min)

  • Children: 0.1 mg/kg

• Alternate for children: diazepam rectal gel (Diastat)

  • 2-5 years: 0.5 mg/kg/dose

  • 6-11 years: 0.3 mg/kg/dose

  • ≥ 12 years: 0.2 mg/kg/dose

6 - 10"

• Start 2nd IV line
• Adults:
  • Thiamine 100 mg IV then
  • Glucose 50% 25-50cc (check glucose 1st, not in stroke)
• Children < 18 months:
  • Pyridoxine 100 - 200 mg IV
  • Glucose 50% 2cc/kg if hypoglycemic
• If seizures persist:
  • Fosphenytoin 20 mg/kg PE IV at 150 mg/min (or IM if no IV access)
  • Do not give phenytoin IM

10 - 20"

• If seizures persist:
  • Fosphenytoin 10 mg/kg PE (total dose 30 mg/kg PE)
• If seizures persist:
  • Intubate
  • Phenobarbital 20 mg/kg IV (at 50 mg/kg for adults, 25 mg/kg)

    OR

  • Valproate sodium [Depacon] 20 mg/kg IV (at 3-6 mg/kg/min)

30 - 60"

• Transfer to ICU
• Arrange for EEG monitoring
• If seizures persist:
  • Phenobarbital 10 mg/kg IV
• If seizures persist:
  • Pentobarbital 5-15 mg/kg load then 1 mg/kg/hour, increase by 0.5-1- mg/kg/hour, titrate to burst-suppression on EEG.

    OR

  • Propofol 3-5 mg/kg load then 1-15 mg/kg/hour

    OR

  • Midazolam 0.2 mg/kg load then 0.05 - 0.2 mg/kg/hour
• Consider folinic acid supplementation for children with intractable status epilepticus

References

1.  Working Group on Status Epilepticus. Treatment of  Convulsive Status Epilepticus. JAMA;1993:854-859.

2. Treiman DM, Meyers PD, Walton NY, Collins JF et al. A Comparison of Four Treatments For Generalized Convulsive Status Epilepticus. NEJM 1998;339:792-798.

3. Lowenstein DH, Bleck T, MacDonald RL. It’s Time to Revise the Definition of Status Epilepticus. Epilepsia 1990; 40: 120-122.

4. Alldredge BK, Gelb AM, Isaacs SM, Corry MD et al. A Comparison of Lorazepam, Diazepam, and Placebo For the Treatment of Out-Of- Hospital Status Epilepticus. NEJM 345:631-637.

5. Classen J,  Hirsch LJ, Emerson RG, Mayer SA. Treatment of Refractory Status Epilepticus with Pentobarbital, Propofol, or Midazolam: A Systematic Review. Epilepsia 2002;43:146-153.

6. van Gestel JPJ, van Oud-Albas HJB, Malingre M, Ververs FFT et al. Propofol and thiopental for refractory status epilepticus in children. Neurology 2005;65:591-592.

7. Prasad A, Worrall BB, Bertram EH, Bleck TP. Propofol and Midazolam in the Treatment of Refractory Status Epilepticus. Epilepsia 2001;42:380-386.

8. Stecker MM, Kramer TH, Raps EC, O’Meeghan R et al.  Treatment of Refractory Status Epilepticus with Propofol: Clinical and Pharmacokinetic Findings. Epilepsia 1998; 39:18-26.

9. Sinha S, Naritoku DK. Intravenous valproate is well tolerated in unstable patients with status epilepticus. Neurology 2000;55:722-724.

10. Manno EM. New Management Strategies in the Treatment of Status Epilepticus. Mayo Clin Proc 2003;78:508-518.

12. Riviello JJ, Holmes GL. The Treatment of Status Epilepticus. Seminars in Pediatric Neurology 2004;11: 129-138.

13. Schor NF, Riviello JJ. Treatment with propofol: The new status quo for status epilepticus? Neurology 2005;65:506-507.

14. Bray RJ. Propofol Infusion syndrome in children. Paediatric Anaesthesia 1998;8:491-499.

15. Lothman E.  The biochemical basis and pathophysiology of status epilepticus. Neurology 1190:40(suppl 2) 13-23.

 

Updated 09/16/2006