Drug regimen for status epilepticus

The emergency treatment for convulsive status epilepticus in the adult consists of the following:

• premonitory stage (pre-hospital stage)
  • diazepam 10−20 mg rectally, repeated once 15 minutes later if status continues to threaten, or
  • midazolam 10 mg given buccally
  • if seizures continue, treat as below.
• early status
  • lorazepam (intravenous) 0.1 mg/kg (usually a 4 mg bolus, repeated once after 10−20 minutes; rate not critical)
  • give usual AED medication if already on treatment
  • for sustained control or if seizures continue, treat as below
• established status
  • phenytoin infusion at a dose of 15–18 mg/kg at a rate of 50 mg/minute or
  • fosphenytoin infusion at a dose of 15−20 mg phenytoin equivalents (PE)/kg at a rate of 50–100 mg PE/minute and/or
  • phenobarbital bolus of 10–15 mg/kg at a rate of 100 mg/minute.
• reafractory status - the refractory stage (general anaesthesia) is reached 60/90 minutes after the initial therapy
  • general anaesthesia, with one of:
    • 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
    • anaesthetic continued for 12−24 hours after the last clinical or electrographic seizure, then dose tapered
  • in some instances, general anaesthesia should be initiated earlier and, occasionally, should be delayed (1)

Note:

• emergency treatment of SE should be administered in parallel with AED therapy. The choice of drugs depends on the following factors:
  • previous therapy
  • the type of epilepsy
  • the clinical setting
• any pre-existing AED therapy should be continued at full dose, and any recent reductions reversed (1)

Reference:

• (1) National Clinical Guideline Centre (NCGC) 2012. The Epilepsies. The diagnosis and management of the epilepsies in adults and children in primary and secondary care.