Author: Charlene Gnisci Melton, PharmD

Educational Pearls:

• Status Epilepticus is defined as continuous seizure activity for >5 minutes, or 2 or more seizures without full return to consciousness between events
• Status epilepticus is a true neurologic emergency with significant morbidity and mortality
• Aggressive, early treatment of status epilepticus is essential as GABA receptors will regress over time and make benzodiazepines less effective as time elapses
• Go large with doses of benzodiazepines and repeat doses if necessary: In adults this means lorazepam 4 mg IV push or Midazolam 10 mg intramuscular if no IV access
• Second line agents include:
• • Levetiracetam (Keppra) 60 mg/kg up to 4500mg
  • Valproic Acid (40 mg/kg up to 3000 mg)
  • Keppra has an arguably better side effect profile and compatibility compared to other second-line agents
• Third line agents include intubation and sedation with propofol, benzodiazepines, or even ketamine

Editor's note: from a time management perspective, call for your second-line treatment early to get it from pharmacy while you slam the benzodiazepines, then it will be arriving hopefully when you need it, and no harm if you don't. Oh, and don't forget a fingerstick glucose.

References

Glauser T, Shinnar S, Gloss D, 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. doi:10.5698/1535-7597-16.1.48

Walker, M.C. Pathophysiology of status epilepticus. Neuroscience Letters. 2018:667:84-91. https://doi.org/10.1016/j.neulet.2016.12.044

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD