This document provides guidelines for the management of status epilepticus (SE), which is defined as continuous seizure activity lasting 5 minutes or more, or recurrent seizures without recovery between seizures. It describes the types of SE, causes, initial steps, and pharmacotherapy management. The principal goals are to stop seizure activity and treat any underlying cause. Initial treatment involves benzodiazepines, followed by anticonvulsants if needed. For refractory SE lasting over 40 minutes, anesthetic doses of medications may be required. The guidelines outline stabilization, initial therapy, second therapy, and third therapy phases for treatment.

1. Guidelinesfor
managementof status
epilepticus

2. Status
Epilepticus ?
 SE was defined as 5 min or more of
 (i) continuous clinical and/or electrographic seizure activity or
 (ii) recurrent seizure activity without recovery (returning to
baseline) between seizures

3. Types
Convulsivestatus
epilepticus
Nonconvulsive
status epilepticus
Refractory SE
 Generalized tonic–
clonic movements of
the extremities.
• may be more likely to
lead to long-term
injury.
• involve jerking
motions, grunting
sounds, drooling, and
rapid eye movements
• Absence or focal
seizures with minimal
motor abnormalities
• People with this type
may appear confused
or look like they're
daydreaming.
• unable to speak and
may be behaving in
an irrational way
• Patients who
continue to
experience either
clinical or electro-
graphic seizures after
receiving adequate
doses of an initial
benzodiazepine
followed by a second
acceptable (AED) will
be considered
refractory.

4. Causes
 Preexisting epilepsy
 CNS tumors
 Drug issues: toxicity, withdrawal or non compliance of AEDs
 Metabolic disturbances: electrolyte abnormalities, hypoglycemia,
renal failure
 CNS infection: meningitis, encephalitis, abscess
 Stroke: ischemic stroke, ICH,SAH cerebral sinus thrombosis
 Head trauma: w/ or w/o epidural or subdural hematoma

5. Management
The principal goalof treatment is to emergently stop both
clinical andelectrographic seizure activity.
Treatment of status epilepticus is time sensitive. It is a
neurological emergency-longerthe patientseizes, the worse
the outcome.
The initial treatment strategy includes:
simultaneousassessment and managementof airway,
breathing, and circulation
seizure abortive drug treatment (i.e., benzodiazepine),
screening for the underlying cause of SE, and immediate
treatment of life-threatening causesof SE (e.g., meningitis,
intracranial mass lesion

6. Initial Steps
 Maintain the ABCDEFG
 Maintain clear airway, position in lateral decubitus (when/if possible to
minimize aspiration risk) or prepare for intubation if needed.
 Vitals should be taken and stabilized, EKG monitoring
 Establish IV access and send for CBC, serum electrolytes, drug serum
levels, and toxicologic screen
 Check blood glucose - in adults, if glucose was < 60 mg, give 50mL
bolus of 50% dextrose IV + 100 mg of thiamine; for children older than
2 years, 2 ml/kg of 25% glucose solution.
 If it is considered necessary, place urinary catheter.
 Once stable - history, examination, and appropriate tests should be
done. Neuroimaging is necessary in new-onset SE. CSF analysis – if
there is suspicion of CNS infection. EEG monitoring should also be
done.

7. 1st Line
Benzodiazepine (first line therapy)They rapidly achieve
therapeutic CNS concentrations after IV administration and act to
potentiate action of (GABA), an inhibitory neurotransmitter in the
CNS,and rapidly abrogate ongoing seizure activity.
Lorazepam
Diazepam
Midazolam.
Their effect is temporary, which is a limitation.

8. Pharmacotherapy Management
Most patients with status epilepticus (SE)who are treated
aggressively with :
AnticonvulsantAgentsare used to terminate clinical and
electrical seizure activity and to prevent seizure recurrence,
but their actions are not immediate so the use of these
agents usually follows administration of an IV
benzodiazepine.
Phenytoinmust be administered slowly and therefore
takes longer than benzodiazepines to enter the brain.
Phenytoin has the advantage of being a long-term
anticonvulsant and can be administered orally after acute
illness.
FosphenytoinA phosphorylated phenytoin prodrug is
highly water-soluble at physiologic pH and therefore is
easier to administer than phenytoin.

9. 3rd Line
 If the patient continues to seize after first and second line
treatment, they are in refractory status epilepticus, so start 3rd
line:
 Phenobarbital- Initial doses of 20 mg/kg infused at a rate of 30 to
50 mg/minute, high risk of prolonged sedation, hypoventilation
and hypotension
 Propofol - Propofol is a highly lipophilic phenol derivative and
GABA-A agonist with anticonvulsant properties. It is poorly
tolerated in patients who are hypotensive, hypovolemic, or
elderly.
 Inhalational anestheticshave been used for refractoryGCSE, but
are seldom used in the modern era.

10. Treatment guidelines
Stabilization phase (0-5 minutes of seizure activity): standardinitial
first aid for seizures and initial assessments and monitoring.

11.  Initial therapy phase: (5-20 minutes of seizure activity) - clear that
seizure requires medical intervention, a benzodiazepine is recommended
as the initial therapy of choice.

12.  Second therapy phase (20-40 minutes of seizure activity): options
include IV fosphenytoin, valproic acid, or levetiracetam. If none of these is
available, IV phenobarbital is a reasonable alternative.

13.  Third therapy phase (40+minutes of seizure activity): if a patient
experiences 40+ minutes of seizure activity, treatment considerations
should include repeating second-line therapy or anesthetic doses of
thiopental, midazolam, pentobarbital, or propofol.

14. References
 Uptodate
 Medscape
 https://emergencymedicinecases.com/status-epilepticus/
 American Epilepsy Society issues guideline and treatment
algorithm for convulsive status epilepticus: https
://www.aesnet.org/about_aes/press_releases/guidelines201
6
 Clinical guideline: status epilepticus in children and adults:
https://www.medigraphic.com/pdfs/revmexneu/rmn-
2019/rmn192i.pdf