Status epilepticus

Posted On January 31, 2023
  • Take care of ABC
  • Urgent tests:
    • CBC, CMP, including Ca, Mg
    • If indicated: anticonvulsant levels if on med, Urine drug screen, Urine HCG
  • Initial
    • Lorazepam (Ativan) 2 – 4 mg iv may repeat once
      • If no iv:
        • Midazolam (Versed) 10 mg IM
        • Buccal Midazolam 10 mg
    • Anticonvulsant: 1 or more of following
      • Phosphenytoin 20 mg/kg iv load
      • Levitiracetam (Keppra) 2000 to 4000 mg iv load over 15 minutes
      • Lacosamide (Vimpat) 200 to 400 mg iv bolus
      • Valproate (Depacon) 20-40 mg iv load
    • Refractory seizure
      • Midazolam (Versed) 0.2 mg/kg blous at 2 mg/min
        • then 0.1-5 mg/kg/hr continuous infusion
        • EEG to burst suppression pattern
        • For 70 kg patient: 10 mg iv load, then 5 mg/hour
    • EEG ASAP
      • In one study, after clinical seizure stopped
      • 14% in nonconvulsive status
      • 34% has intermittent seizure > 10 seconds on EEG
  • Special situation
    • Epilepsia partialis continua
      • may need benzodiazepine
      • even with multiple med, often do not stop jerking
    • Benign myoclonic seizure
      • Consider Benzo, valproate or Levetiracetam
    • Post Hypoxic Myoclonus
      • Same as above, but prognosis poor