Status Epilepticus
Background1:
i.
ii.
Seizure: Abnormal electrical activity in the brain.
Status Epilepticus: Seizure lasting >5 minutes or multiple seizures within 5 minutes without a
return to baseline consciousness.
Presentation1:
i.
ii.
Convulsive Status Epilepticus
a. Jerking
b. Grunting
c. Drooling
d. Rapid eye movements
e. More likely to lead to long term injury
Non-convulsive Status Epilepticus
a. Confusion
b. Day-dreaming appearance
c. Inability to speak
d. Irrational behavior
Causes1:
i.
ii.
Common Causes:
a. Fever
b. Abnormal sodium levels
c. Abnormal glucose levels
d. Head injuries
e. Alcohol intoxication or withdrawal
Risk Factors
a. Poorly controlled epilepsy
b. Low blood sugars
c. Stroke
d. Kidney or liver failure
e. Encephalitis
f. HIV
g. Alcohol or drug abuse
h. Genetic diseases
i. Fragile X syndrome
ii. Angelman syndrome
i. Previous head injury
Diagnosis2:
i.
ii.
iii.
EEG
CT/MRI
Lumbar Puncture
Treatment3:
i.
Phase
a. Stabilization Phase: 0 – 5 minutes
i. Stabilize patient
1. Airway, breathing, circulation, neurologic exam
ii. Record time of seizure onset
iii. Initiate ECG monitoring
iv. Collect blood glucose
1. If glucose < 60 mg/dL, give 100mg thiamine IV then 50 mL D50W IV
v. Attempt IV access
1. Toxicology Screen
2. CMP
3. Anticonvulsant levels if needed
b. Initiation Phase: 5 – 20 minutes
i. First line options
1. IM midazolam
a. If 13 – 40 kg, give 5 mg once
b. If >40 kg, give 10 mg once
c. Do not repeat dosing
2. IV lorazepam
a. 0.1 mg/kg/dose (max of 4 mg/dose)
b. May repeat dose once
3. IV diazepam
a. 0.15 - 0.2 mg/kg/dose (max of 10 mg/dose)
b. May repeat dose once
c. Second Therapy Phase: 20 – 40 minutes
i. Second line options
1. IV fosphenytoin
a. 20 mg/kg/dose (max of 1500 mg/dose)
b. Do not repeat dosing
2. IV valproic acid
a. 40 mg/kg/dose (max of 3000 mg/dose)
b. Do not repeat dosing
3. IV levetiracetam
a. 60 mg/kg/dose (max of 4500 mg/dose)
b. Do not repeat dosing
d. Third Therapy Phase: 40 – 60 minutes
i. Repeat second line options or give anesthetic doses of thiopental, midazolam,
pentobarbital, or propofol
ii. Continuous EEG monitoring
References
1. Status Epilepticus. Johns Hopkins Medicine. (n.d.).
https://www.hopkinsmedicine.org/health/conditions-and-diseases/status-epilepticus.
2. Cedars-Sinai Status Epilepticus. Cedars. (n.d.). https://www.cedars-sinai.org/healthlibrary/diseases-and-conditions/s/status-epilpeticus.html.
3. Glauser, T., Shinnar, S., Gloss, D., Alldredge, B., Arya, R., Bainbridge, J., Bare, M., Bleck, T.,
Dodson, W. E., Garrity, L., Jagoda, A., Lowenstein, D., Pellock, J., Riviello, J., Sloan, E., & Treiman,
D. M. (2016). Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children
and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy
Currents, 16(1), 48–61. https://doi.org/10.5698/1535-7597-16.1.48