Status Epilepticus Medication Protocol

Status epilepticus is a seizure lasting 5 minutes or more, or repeated seizures without recovery between them. Treatment follows time stages: a benzodiazepine within 5 to 10 minutes, a second-line drug by 20 to 30 minutes, and anaesthesia for refractory status.

Immediate care. Airway, oxygen, glucose check, intravenous access and monitoring. Give glucose if low and thiamine if alcohol use or malnutrition is likely.

Cause. Search for and treat hypoglycaemia, electrolyte disorder, infection, stroke, trauma, toxins, alcohol withdrawal, eclampsia and missed antiepileptic drugs.

Stage 1 (0 to 10 minutes). A benzodiazepine: lorazepam intravenously, midazolam intramuscularly or buccally, or diazepam intravenously or rectally.

Stage 2 (10 to 30 minutes). Levetiracetam, phenytoin or fosphenytoin, valproate or phenobarbital.

Stage 3 (refractory). Anaesthesia with propofol, midazolam, thiopental or ketamine, on an intensive care unit.

Specific causes. Magnesium sulphate for eclampsia. Pyridoxine for isoniazid toxicity and in infants. Glucose for hypoglycaemia.

Special groups.

• Children: weight-based doses and age-based buccal midazolam.

• Pregnancy: magnesium sulphate for eclampsia, and avoid valproate unless no alternative exists.

• Older adults: monitor for non-convulsive status.

• East Africa: cerebral malaria, central nervous system infection, neurocysticercosis, HIV and eclampsia are common causes. Check glucose, treat malaria and hypoglycaemia, and use phenobarbital when it is the only second-line drug available.

• Lorazepam: 4 mg intravenously (0.1 mg/kg, maximum 4 mg), repeated once after 5 to 10 minutes.

• Midazolam: 10 mg intramuscularly in adults over 40 kg, 5 mg for 13 to 40 kg. Buccal, 10 mg in adults. Children 0.3 mg/kg buccal (maximum 10 mg).

• Diazepam: 0.15 to 0.2 mg/kg intravenously (maximum 10 mg), repeated once. Rectal 10 mg in adults, 0.5 mg/kg in children.

• Levetiracetam: 60 mg/kg intravenously over 10 minutes (maximum 4500 mg).

• Phenytoin: 20 mg/kg intravenously at no more than 50 mg/min with ECG monitoring. Fosphenytoin 20 mg phenytoin equivalents/kg at up to 150 mg/min.

• Valproate: 40 mg/kg intravenously over 10 minutes (maximum 3000 mg).

• Phenobarbital: 15 mg/kg intravenously at 50 to 100 mg/min.

• Refractory: midazolam 0.2 mg/kg bolus, then 0.1 to 0.4 mg/kg/h. Propofol 2 mg/kg bolus, then 2 to 5 mg/kg/h with short duration. Ketamine 1 to 2 mg/kg bolus, then 0.5 to 5 mg/kg/h. Aim for seizure control or burst suppression on EEG.

• Eclampsia: magnesium sulphate 4 g intravenously over 5 to 15 minutes, then 1 g/h for 24 hours.

• Isoniazid toxicity: pyridoxine intravenously, equal in grams to the isoniazid dose taken, or 5 g if unknown.

Monitoring. Respiratory rate, oxygen saturation, ECG, blood pressure, glucose, blood gases and creatine kinase. Continuous EEG for refractory cases.

Stop rules. Stop escalation when seizures stop, and continue maintenance antiepileptic drugs. Reduce anaesthesia after 24 to 48 hours of control.

Referral and escalation. Call intensive care and neurology for seizures continuing after 2 drugs, need for intubation, or suspected non-convulsive status.

Common errors. Under-dosing benzodiazepines, giving phenytoin too fast, delaying second-line drugs, missing hypoglycaemia, and omitting a cause search.