Status epilepticus is a life-threatening condition involving prolonged or repeated seizures without recovery between seizures. Intravenous administration of anti-seizure medications is required for treatment. Diazepam or lorazepam are usually effective for terminating seizures in the short-term, while phenytoin or fosphenytoin are preferred for prolonged therapy due to being highly effective with less sedation. If seizures are not controlled by first-line treatments, phenobarbital may be used, and refractory cases may require general anesthesia. Close monitoring is important due to risks of respiratory depression, hypotension, and cardiotoxicity from some medications.

1. STATUS EPILEPTICUS
PharmD St. Isa BADUR
Clinical Pharmacy, Istanbul Medipol
Universty

4. ILAE-IBE

7. eeg

14. gilman
• Drugs should be administered intravenously.
• Four regimens have similar success rates of
44–65%: diazepam followed by phenytoin;
lorazepam; phenobarbital; and phenytoin
alone.
• Studies show no significant differences with
respect to recurrences or adverse reactions

15. gilman
Intravenous diazepam or lorazepam is usually
effective in terminating attacks and providing
short-term control.
For prolonged therapy, intravenous phenytoin
has often been used because it is highly
effective and less sedating than
benzodiazepines or barbiturates.

16. gilman
However, phenytoin may cause cardiotoxicity (perhaps
because of its solvent propylene glycol), and
fosphenytoin (watersoluble) is a safer parenteral agent.
Phenobarbital has also been used in status epilepticus,
especially in children. In very severe status epilepticus
that does not respond to these measures, general
anesthesia may be used.

17. katzung
There are many forms of status epilepticus.
The most common,generalized tonic-clonic
status epilepticus, is a life-threatening
emergency, requiring immediate cardiovascular,
respiratory, and metabolic management as well
as pharmacologic therapy.

18. katzung
The latter virtually always requires intravenous administration of
antiseizure medications.
Diazepam is the most effective drug in most patients for stopping
the attacks and is given directly by intravenous push to a
maximum total dose of 20–30 mg in adults.
Intravenous diazepam may depress respiration (less frequently,
cardiovascular function), and facilities for resuscitation must be
immediately at hand during its administration.

19. katzung
The effect of diazepam is not lasting, but the 30- to 40-minute
seizure-free interval allows more definitive therapy to be
initiated.
Some physicians prefer lorazepam, which is equivalent to
diazepam in effect and perhaps somewhat longer acting.
For patients who are not actually in the throes of a seizure,
diazepam therapy can be omitted and the patient treated at
once with a long-acting drug such as phenytoin.

20. katzung
Until the introduction of fosphenytoin, the
mainstay of continuing therapy for status
epilepticus was intravenous phenytoin, which is
effective and nonsedating.
It can be given as a loading dose of 13–18 mg/kg
in adults; the usual error is to give too little.
Administration should be at a maximum rate of
50 mg/min.

21. Katzung
It is safest to give the drug directly by intravenous
push, but it can also be diluted in saline; it
precipitates rapidly in the presence of glucose
Careful monitoring of cardiac rhythm and blood
pressure is necessary, especially in elderly people.
At least part of the cardiotoxicity
is from the propylene glycol in which the phenytoin
is dissolved.

22. katzung
Fosphenytoin, which is freely soluble in intravenous
solutions without the need for propylene glycol or other solubilizing
agents, is a safer parenteral agent. Because of its greater
molecular weight, this prodrug is two thirds to three quarters as
potent as phenytoin on a milligram basis.
In previously treated epileptic patients, the administration of a
large loading dose of phenytoin may cause some dose-related toxicity
such as ataxia. This is usually a relatively minor problem
during the acute status episode and is easily alleviated by later
adjustment of plasma levels.

23. katzung
For patients who do not respond to phenytoin, phenobarbital
can be given in large doses: 100–200 mg intravenously to a total of
400–800 mg. Respiratory depression is a common complication,
especially if benzodiazepines have already been given, and there
should be no hesitation in instituting intubation and ventilation.
Although other drugs such as lidocaine have been recommended
for the treatment of generalized tonic-clonic status epilepticus,
general anesthesia is usually necessary in highly resistant
cases.
For patients in absence status, benzodiazepines are still drugs of
first choice. Rarely, intravenous valproate may be required

24. Extracranial causes

25. Partial seizures, simple
Seizures Finite episodes of brain dysfunction
resulting from abnormal discharge of cerebral
neurons
Partial seizures, simple Consciousness
preserved; manifested variously as convulsive
jerking, paresthesias, psychic symptoms (altered
sensory perception, illusions, hallucinations,
affect changes), and autonomic dysfunction

27. Partial seizures, Complex
Partial seizures, Complex Impaired
consciousness that is preceded, accompanied,
or followed by psychological symptoms

29. Tonic-clonic seizures, generalized
Tonic phase (less than 1 min) involves abrupt
loss of consciousness, muscle rigidity, and
respiration arrest; clonic phase (2–3 min)
involves jerking of body muscles, with lip or
tongue
biting, and fecal and urinary incontinence;
formerly called grand mal

32. Absence seizures
Absence seizures, generalized
Impaired consciousness (often abrupt onset and
brief), sometimes with automatisms, loss of
postural tone, or enuresis; begin in childhood
(formerly, petit mal) and usually cease by age 20
yrs
Myoclonic seizures Single or multiple myoclonic
muscle jerks

35. Absence seizures

36. Status epilepticus
• Status epilepticus A series of seizures (usually
tonic-clonic) without recovery of
consciousness between attacks; it is a life-
threatening emergency

37. s. epilepticus
• 1. a continuous series of generalized tonic-clonic
seizures without return to consciousness, a life-
threatening emergency. Called also convulsive s.
epilepticus. convulsive s. epilepticus, tonic-clonic
s. epilepticus
• 2. any prolonged series of similar seizures
without return to full consciousness between
them; the two major types are convulsive s.
epilepticus, which is life-threatening, and
nonconvulsive s. epilepticus, which is serious but
not usually life-threatening.

38. Nanconvulsive status epilepticus
• s. epilepticus, nonconvulsive status epilepticus
that does not include generalized tonic-clonic
seizures; see complex partial s., petit mal s.,
and epilepsia partialis continua.

39. STATUS EPILEPTICUS
• Status epilepticus is a neurological emergency.
Mortality for adults is ~20%. The goal of
treatment is rapid termination of behavioral
and electrical seizure activity; the longer the
episode of status epilepticus is untreated, the
more difficult it is to control and the greater
the risk of permanent brain damage.
• .

40. STATUS EPILEPTICUS
• Critical to the management are a clear plan,
prompt treatment with effective drugs in
adequate doses, and attention to
hypoventilation and hypotension.
• Since the high doses of drugs used may cause
hypoventilation, it may be necessary to assist
respiration temporarily.

44. lorazepam

45. diazepam

46. fosphenytoin

47. Phenıytoin

48. phenobarbitone

49. İf refractory

50. monitor