Definition

Continuous seizure or ≥ 2 discrete seizures with incomplete return of consciousness between seizures lasting ≥ 5 minutes.

Management

• Initial assessment/stabilization:
  • Airway protection (head positioning, supplemental oxygen, intubation as needed)
  • Vital signs including vasopressor support as needed
  • Finger stick glucose 
    • If blood glucose < 60 mg/dL, give 100 mg thiamine then 50mL of 50% dextrose
• Emergent treatment: 
  • Rapid benzodiazepine administration with one of the following:
    • Lorazepam 4 mg IV as a single dose, may repeat once for ongoing seizures
    • Midazolam 10 mg IM as a single dose
  • If seizures continue, diazepam 0.25 mg/kg IV (max 10 mg). Administer second-line anti-epileptic drug (AED) treatment with one of the following:
  • Fosphenytoin 20 mg PE/kg (max 1500 mg PE) IV
  • Valproic acid 40 mg/kg (max 3000 mg) IV
  • Levetiracetam 20-60 mg/kg (max 4500 mg) IV
• If seizures continue despite second-line AED, patient has refractory status epilepticus (approximately 30% patients). Start treatment with third-line therapy: propofol, midazolam, pentobarbital, or thiopental (with intubation and continuous EEG monitoring). Initiate work-up for cause of status epilepticus (see section Seizures)
• Monitor patients for multiple medical complications related to status epilepticus and its associated treatment

Glauser T, Shinnar S, et al. Evidence-Based Guideline: Treatment of convulsive status epilepticus in children and adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61

Betjemann and Lowenstein, Status epilepticus in adults, The Lancet Neurology 2015; 6: 615-624Legriel, S. Crit Care Med. 2010 Dec;38(12):2295-303.

Prasad, M. Cochrane Database Syst Rev. 2014 Sep 10;9:CD003723