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Status Epilepticus

Dr Swapnil Pawar June 6, 2022 24


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    Status Epilepticus
    Dr Swapnil Pawar

Status Epilepticus

Blog written by Dr Ashly Liu

Definition

A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes is called status epilepticus. 

Approach to Management

Timing of Seizure Management
0 – 5 min – Seizure Usually self-limiting
5 – 20 min – Status epilepticus Benzodiazepines (ideally IV)

  • Midazolam 5 mg and repeat of 2.5mg at 2-3minutes
>20min – Refractory status epilepticus Anti-epileptics – loading dose

  • Levetiracetam 60mg/kg
  • Sodium Valproate 20mg/kg
  • Phenytoin 20mg/kg
If refractory, consider termination of seizure via Rapid Sequence Induction (RSI)

 

Pharmacotherapy Options

Benzodiazepines (as per eTG)

  • Clonazepam 1mg IV over 2-5 minutes. Repeat once 15 min later if ongoing status epilepticus
  • Diazepam 10-20mg IV over 2-5 minutes. Repeat once 15 min later if ongoing status epilepticus
  • Midazolam 5-10mg bolus IM, IV or buccally or intranasally
    • For IV, start 5mg bolus and onset 30s, then 2.5mg at 2-3min intervals. Once it hits 10-15mg, start considering other agents
    • For paediatric patients, 0.15mg/kg bolus

If the seizure continues for 10min despite benzodiazepines, further anticonvulsant loading is required.

Anti-epileptics

The following anti-epileptics have shown to be equally efficacious by the ESTT trial

  • Phenytoin – 20mg/kg
    • Has increased associated risk of bradyarrhythmia and hypotension
  • Sodium valproate – 20mg/kg (max 3000mg)
    • Risks: avoid in pregnancy
  • Levetiracetam – 60mg/kg (max 4500 mg)
    • Preferred in pregnancy

If refractory, RSI and propofol as the last line to terminate the seizure

 

Sources: https://aci.health.nsw.gov.au/networks/eci/clinical/clinical-tools/neurology/seizures/seizure-medications

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