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Emergency Management of Status Epilepticus

Among the presentations seen in the ED, few command the same respect as status epilepticus. It is, in itself, both a diagnostic dilemma and, at times, a therapeutic nightmare. There’s a reason it’s the very first domino to fall in the dreaded sequence “seizure, coma, death”. Status epilepticus can be nuanced to manage. Sure, most seizures self-abort or love an IV dose of lorazepam, but ask anyone who’s been down the propofol route, and they’re not likely to have forgotten the time they stared down a patient who just…would…not….stop.

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 EBM: Seizure Management in the Emergency Department

Lorazepam 0.1mg/kg IV, or fixed dose of 4mg, If no IV/IO access then midazolam 0.2 mg/kg or 10mg IM/buccal/IN or 20mg rectally can be used.

 The Status on Status: Management of Status Epilepticus

Instead of a stepwise, watch-and-wait approach, perhaps multiple management steps should happen in parallel.

Articles of Interest

Management of Status Epilepticus

Where most seizures are brief and self-limiting, convulsive SE is defined as a seizure that persists for at least 5 minutes or is the situation in which seizures are recurrent and there is no return to baseline in between. Seizure rates differ among different patient groups with the highest risk seen after acute ischemic stroke.

Refractory Status Epilepticus: Pearls and Pitfalls for the Resuscitation Room

Refractory GCSE is defined as persistent seizure activity despite treatment with both benzodiazepines and intravenous antiepileptic medications such as phenytoin, phenobarbital, or levetiracetam leading to inevitable generalized sedation and subsequent intubation.

Seizure & Status Epilepticus

Benzodiazepines are the first line treatment for seizures in the ED

Status Epilepticus: Emergency Management

It really doesn’t matter which benzodiazepine you pick – they all work. (Glauser 2016) Usually this first dose will have already been given before the patient arrives. If an IV has not been started, I will immediately give intramuscular or intranasal midazolam.

Resources

EMcrit Project

Treatment is extremely challenging, with seizures often being refractory to multiple medications. Some restraint may be needed, as the treatment may be more dangerous than the disease itself.

Life in the Fastlane

Continuous seizure activity for 5 minutes or more without return of consciousness, or recurrent seizures (2 or more) without an intervening period of neurological recovery.

WikEM

Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments or recurrent seizure activity without return to baseline mental status. (Previous definitions used a 30-minute time limit).