STATUS EPILEPTICUS


I. Definition: Seizures lasting >30min or recurrent seizures of total duration >30min without fully regaining consciousness

II. Evaluation--Diagnostic studies to consider

  1. Measurement of anticonvulsant drug levels if the pt is on anticonvulsants
  2. Toxicology testing
  3. Testing for inborn errors of metabolism
  4. Neuroimaging
  5. EEG
  6. Blood culture and/or lumbar puncture IF there is clinical suspicion of infection

III. Treatment

  1. Lorazepam 0.1-0.15 mg/kg IV is commonly used as 1st-line as of 2010 (less risk of respiratory depression than diazepam)
  2. Midazolam is also an option and may be given via non-IV routes (buccally, IM, or intranasal)
  3. 2nd-line: Phenytoin, fosphenytoin, phenobarbital
  4. 518 pts with status epilepticus randomized to one of the following IV, with the following "success rates" (cessation of sz < 20min after starting the med and no recurrent sz x 40min); The diff. between Lorazepam and phenytoin was statistically significant; Freq. of sz recurrence at 12h not sig. diff. between groups (NEJM 339:792, 1998--JW)
    1. Lorazepam--65%
    2. Phenobarbital--58%
    3. Phenytoin--44%
    4. Diazepam + Phenytoin--56%
  5. For children in whom IV access cannot easily be obtained:
    1. Diazepam PR
    2. Midazolam IV formulation administered buccally (associated with sig. higher incidence of successful control of seizures within 10min and for at least 1h w/o respiratory repression--56% vs. 27%--compared with rectal diazepam in a randomized study in 177 children > 6mos old--Lancet 366:205, 2005--JW)