1. Be sure of the diagnosis. Distinguish from myoclonus, other movement disorders, decerebrate posturing, and nonepileptic seizures. Blood gases and EEG may be helpful. After 30 minutes of recurrent seizures without recovery, the patient should be considered in SE. With continuous seizures, treatment should start earlier, probably after 5 minutes.
  2. Determine the causes of SE through history, examination, and appropriate laboratory tests. Neuroimaging is necessary in new-onset SE; cerebrospinal fluid analysis is necessary if there is suspicion of central nervous system infection.
  3. Note status of airway, respiration, blood pressure, and cardiac rhythm. Most patients with generalized convulsive status epilepticus (GCSE) require intubation. Patients with other forms of SE often do not. Establish an intravenous line with saline, and administer thiamine and glucose. Give antibiotics when infection is a possibility. Draw blood for metabolic studies, determination of anticonvulsant levels, and toxic screens.
  4. Administer rapidly acting anticonvulsants (i.e., benzodiazepines) if GCSE has lasted 30 minutes, if convulsions are continuous, if convulsions occur during the infusion of phenytoin or phenobarbital, or if phenytoin or phenobarbital is not successful. Lorazepam, 4 to 8 mg (0.1-0.2 mg/kg) in adults, can be given at a rate of <2 mg/min and repeated if necessary.
  5. Use a long-acting medication. Fosphenytoin, the most frequently used maintenance medication, should be given in saline at 150 mgPE/min, with attention to blood pressure and the cardiogram, to a dose of 18 to 20 mg/kg rather than the commonly used 1000 mg. Phenobarbital is more often used for children, seniors, or patients with cardiac rhythm disturbances, at 10 to 20 mg/kg, up to 100 mg/min, with attention to blood pressure.
  6. If above agents are unsuccessful or 30 to 45 minutes have transpired with continuing seizures, admit to intensive care unit, intubate, and provide definitive treatment with midazolam, propofol or pentobarbital. (See text for appropriate loading doses.) [Link to 06 Management.] Continuous EEG monitoring is mandatory at this point and staff should be prepared to support blood pressure with inotropic medications. The goal is to eliminate seizure activity on the EEG; many physicians proceed to burst-suppression EEG tracings. Maintenance dosages are adjusted as needed to control seizures and attain the desired EEG recording.
  7. Continue maintenance anesthetic doses for 24 hours or longer after the desired end point is reached, while oral anticonvulsant medications are administered or adjusted to achieve high therapeutic levels. Anesthetic doses are then tapered by half and discontinued gradually, observing for seizure recurrence.
  8. Continue to reassess clinical and EEG activity and attend to the diagnosis and medical complications, until the patient returns to normal.
  9. Attend to complications such as hypothermia, acidosis, hypotension, rhabdomyolysis, renal failure, infection, and cerebral edema.

Adapted from: Drislane FW. Status epilepticus. In: Schachter SC, Schomer DL, eds. The comprehensive evaluation and treatment of epilepsy. San Diego, CA: Academic Press; 1997. p. 149-172. With permission from Elsevier (www.elsevier.com).

Authored By: 
Frank W. Drislane MD
Reviewed By: 
Thaddeus Walczak MD
Wednesday, December 31, 2003