Status Epilepticus – Adults

Last Updated on by frcemuser

Emergency antiepileptic drug therapy

Early status

  • Administer IV 4 mg lorazepam (lorazepam 0.1 mg/kg IV) slowly into a large vein (diazepam 10 mg is an alternative) Repeat lorazepam 4 mg slowly after 10 minutes if seizures continue
  • If there is no venous access, buccal 10 mg midazolam (can be repeated once) or rectal diazepam solution( Diazepam 0.5 mg/kg) 10– 20 mg (can be repeated up to a maximum 30 mg) are alternatives

Established status (Seizure after 20 mins?)

  • If seizures continue despite benzodiazepines ( 2 doses), ITU should be contacted and phenytoin infusion can be started (18 mg/kg IV, 50 mg/min) or fosphenytoin infusion (20 mg phenytoin equivalents/kg IV, <150 mg/min)
  • Depends on the institutions
    • levetiracetam – 60 mg/kg up to a max total dose of 4.5 grams, infused over 10 minutes or
    • valproic acid – 40 mg/kg (up to 3,000 mg) infused over 5-10 minutes

Refractory status (Seizure after 40 mins?)

  • Proceed without delay to rapid sequence induction with IV propofol, midazolam or thiopental
    • Propofol (1–2 mg/kg bolus, then 2–10 mg/kg/hour) titrated to effect
    • Midazolam (0.1–0.2 mg/kg bolus, then 0.05–0.5 mg/kg/hour) titrated to effect
    • Thiopental sodium (3–5 mg/kg bolus, then 3–5 mg/kg/hour) titrated to effect; after 2–3 days infusion rate needs reduction as fat stores are saturated
  • Prepared to manage hypotension (Norephdrine infusion or push of epinephrine)
  • For severely hypotensive patients, a midazolam infusion may be used instead of propofol.

Other Medications:

  • If alcohol abuse or withdrawal is suspected, give slow IV thiamine (2 pairs of Pabrinex ampoules in 100 ml of 0.9% saline)
  • Pregnancy – Eclamsia – Magnesium sulphate IV
  • hyponatremia –  bolus of 150 ml 3% saline
  • hypoglycemia – give IV glucose  (1-2 ampules of D50W)

 

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