As with many neurocritical care topics, there is no big evidence for status therapy, which is why the various guidelines differ dramatically, if only in the dose of drugs to be used. Since the german guidelines have just been released (though not online yet – hate them for it), it is time to review the basic steps (all the following is for Germany, only):
- Status is when seizures take longer than 5 minutes (all guidelines agree on this, all original papers use different definitions)
- If in doubt, give Thiamine 100 mg, Glucose (say 2-4 ampules of 40% dextrose) and (this is my personal recommendation and not really the guidelines) an ampule of Mg.
- Monitor and ensure monitoring.
- Make sure that an adequate dose of benzoshas been given
- Lorazepam is preferred (0,05 mg/kg, at most twice)
- Diazepam is mostly used by the Notarzt, because it needn’t be cooled – 0,15 mg/kg < 10 mg, at most twice
- Midazolam 0,2 mg/kg can be given im or buccaly or any other way
- If this fails, hit them with a non-sedating antiepileptic
- Valproate 20-30 mg/kg (may be repeated with 10 mg/kg after 10 min) with 10mg/kg/min (an ampule of 300 mg a minute is ok)
- Phenytoin 20 mg/kg (may be repeated with 10 mg/kg) with only 50 mg/min (which is why we rarely use it – takes over half an hour to be completed)
- Levetiracetam 30-60 mg/kg (may be repeated full dose after 10 min)
- Lacosamid is offered as an option with 5 mg/kg over 15 mins (too slow for my taste)
- Next step, narcotic anticonvulsants(intubate, EEG controlled – Burst suppression)
- Midazolam bolus 0,2 mg/kg, continuous infusion with 0,1-0,5 mg/kg/h
- Disoprivan bolus 2 mg/kg, continuous infusion with 4-10 mg/kg/h
- Thiopental bolus 5 mg/kg, continuous infusion with 3-7 mg/kg/h
All this should happen in less than an hour in the case of generalized or complex partial convulsive status epilepticus.
For non-convulsive, things go a bit slower, preferably with less sedating agents and without intubation, if possible.
Personally I often omit step 1 if the beginning of status lies back more than 15 mins (as usually is the case in the ER) as benzos probably don’t work so well then (due to internalization of GABA_A-receptors).
As last resort, our guidelines offer the following
- Ketamine (good idea because of Glutamate antagonism) bolus of about 1 mg/kg, then 0,3-5,8 mg/kg/h
- Lidocaine bolus 1-2 mg/kg, 1-4 mg/kg/h
- Dexamethasone (how much?)
- Sevoflurane and other inhalational anaesthetics
- The German guidelines are not online yet
- The European guidelines 2009 differ a lot
- The American guidelines 2012 resemble the European ones (or vice versa)
- A recent expert review on this topic