The guideline committee of the American Epilepsy Society has released a new treatment guideline for convulsive status epilepticus — the most common type of status epilepticus that is associated with substantial mortality.
The American Epilepsy Society estimates that between 50 000 and 150 000 Americans have status epilepticus each year, with mortality rates just under 3% for children and up to 30% for adults. Current treatment of status epilepticus varies, with some approaches focused more on seizure reduction rather than termination. These less aggressive methods may prolong status epilepticus beyond the 30-minute mark when neurologic injury can occur.
The new guideline, published in the January/February issue of Epilepsy Currents, is based on an assessment of 38 randomized controlled trials. It provides practitioners with evidence-based answers that address questions regarding efficacy, safety, and tolerability. The answers to those questions have been incorporated into a treatment algorithm that is broken out into 4 phases, meant to guide treatment through the 60-minute mark.
Stabilization Phase (0-5 minutes seizure activity)
- Includes standard stabilization of patient, seizure timing, initiation of ECG monitoring, blood glucose test, and IV access.
Initial Therapy Phase (5-20 minutes)
- Benzodiazepines are the initial therapy of choice: Choose one of the following
- Intramuscular midazolam (10 mg for > 40 kg, 5 mg for 13-40 kg, single dose, Level A) OR
- Intravenous lorazepam (0.1 mg/kg/dose, max: 4 mg/dose, may repeat dose once, Level A) OR
- Intravenous diazepam (0.15-0.2 mg/kg/dose, max: 10 mg/dose, may repeat dose once, Level A)
- If none of the 3 options are available, choose one of the following:
- Intravenous phenobarbital (15 mg/kg/dose, single dose, Level A) OR
- Rectal diazepam (0.2-0.5 mg/kg, max: 20 mg/dose, single dose, Level B) OR
- Intranasal midazolam (Level B), buccal midazolam (Level B)
Second Therapy Phase (20-40 minutes)
- At this point, a response to the therapy administered in the previous phase should be evident. If there is a lack of response, the following can be administered as a single dose (note that there is no evidence-based preferred therapy of choice):
- Intravenous fosphenytoin (20 mg PE/kg, max: 1500 mg PE/dose, single dose, Level U) OR
- Intravenous valproic acid (40 mg/kg, max: 3000 mg/dose, single dose, Level B) OR
- Intravenous levetiracetam (60 mg/kg, max: 4500 mg/dose, single dose, Level U)
- If none of the options are available, choose the following (if not given already)
- Intravenous phenobarbital (15 mg/kg, single dose, Level B)
Third Therapy Phase (40-60 minutes)
- At this point, there is no clear evidence to guide therapy.
- If the patient is still seizing, clinicians may repeat the second line therapy or administer anesthetic doses of thiopental, midazolam, pentobarbital, or propofol, all while under continuous EEG monitoring.
Based on the cause and severity of the seizure, clinicians may move through the therapy phases faster, or skip to more advanced phases if deemed appropriate. If at any point the patient responds to therapy and is at baseline, symptomatic medical care should be initiated.