GIM Question 25 Instructor

What is the definition of status epilepticus?
Status epilepticus is defined as continuous seizure activity for more than 5 min, or two or more discrete seizures without regaining complete consciousness in between.

Outline your management of this condition.
Treatment is aimed at stopping the seizure and stabilizing the patient:

  • ABC, O2, large bore IV insertion
  • Accucheck for blood glucose: administer D50W 1 ampule IV if hypoglycemic
  • First-line therapy:
    • Lorazepam 2-4mg IV q2min (up to 0.1mg/kg IV, MAX 8-10mg)
    • Diazepam 5-10mg IV (up to 0.15mg/kg IV, MAX 20-30mg) if Lorazepam not available (duration of action < lorazepam)
    • Midazolam 10mg IM (for patients >40kg) if unable to obtain IV access

If seizure activity does not resolve after 5min with first-line therapy, help should be sought immediately, and second-line therapy initiated through a second IV site:

  • Phenytoin 20mg/kg IV at a rate of 25-50mg/min
  • Fosphenytoin 20 PE/kg IV or IM at a rate of 100-150 PE/min

Third-line therapy (if the maximum dose of the above medications is reached) – ICU team should be consulted at this point:

  • Phenobarbitol 20mg/kg IV at 50mg/min
  • Midazolam 0.2mg/kg IV loading dose and then infusion of 0.05-0.5mg/kg/hr
  • Propofol: 2-5mg/kg IV loading dose and then 10mg/kg/hr

Marik PE and Varon J. The management of status epilepticus. Chest. 2004, 126:582-591.

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