Status Epilepticus Management (AES 2016)

Algorithm Steps

1. ▶

   Start

   Ongoing Seizure Activity

   Convulsive seizure >5 min OR recurrent without recovery

   1. ●

      Action

      Stabilization Phase (T0)

      ABCs, IV access, glucose check

      • TIME IS CRITICAL - note exact seizure onset
      • Position safely, protect airway
      • Check fingerstick glucose - treat if <60 mg/dL
      • Thiamine 100mg IV if suspected alcohol use/malnutrition
      • Establish IV access (or IO if IV fails)
      1. ●

         Action

         First-Line: Benzodiazepine (0-5 min)

         IMMEDIATE benzodiazepine administration

         • IV LORAZEPAM: 0.1 mg/kg (max 4mg), may repeat once
         • IV DIAZEPAM: 0.15 mg/kg (max 10mg), may repeat once
         • IM MIDAZOLAM: 10mg if >40kg, 5mg if 13-40kg (no IV)
         • INTRANASAL MIDAZOLAM: 0.2 mg/kg (max 10mg)
         • RECTAL DIAZEPAM: 0.2-0.5 mg/kg (max 20mg)
         1. ◆

            Decision

            Seizure Stopped? (at 5-10 min)

            Reassess after first-line therapy

            1. ✓

               Outcome

               Seizure Terminated

               Continue monitoring, determine cause

            2. ●

               Action

               Second-Line Therapy (5-20 min)

               Urgent control medication - choose ONE

               • FOSPHENYTOIN: 20 mg PE/kg IV (max rate 150 mg PE/min)
               • VALPROATE: 40 mg/kg IV (max rate 10 mg/kg/min, max 3000mg)
               • LEVETIRACETAM: 60 mg/kg IV (max 4500mg) over 15 min
               • PHENOBARBITAL: 15 mg/kg IV (if others unavailable)
               • Prepare for intubation if no response
               1. ●

                  Action

                  Concurrent Workup

                  Do not delay treatment for workup

                  • Labs: BMP, Mg, Ca, CBC, AED levels
                  • CT head (after stabilization)
                  • LP if infection suspected
                  • Toxicology screen
                  • Consider MRI when stable
               2. ◆

                  Decision

                  Seizure Stopped? (at 20-40 min)

                  Reassess after second-line therapy

                  1. ●

                     Action

                     Post-SE Monitoring

                     ICU admission, EEG monitoring

                     • Continuous EEG if available
                     • Watch for non-convulsive SE
                     • Determine etiology (labs, imaging)
                     • Initiate maintenance AED therapy
                     1. ✓

                        Outcome

                        Controlled

                        Seizures terminated, begin maintenance therapy

                  2. ⚠

                     Warning

                     REFRACTORY Status Epilepticus

                     Seizure continues after adequate 1st & 2nd line therapy

                     • Definition: SE persisting after adequate treatment
                     • Requires ICU admission
                     • Continuous IV anesthetics
                     • Intubation required
                     1. ●

                        Action

                        Third-Line: Anesthetic Therapy

                        Continuous IV anesthetics with EEG monitoring

                        • MIDAZOLAM infusion: 0.2 mg/kg bolus, then 0.1-2 mg/kg/hr
                        • PROPOFOL: 1-2 mg/kg bolus, then 20-200 mcg/kg/min
                        • PENTOBARBITAL: 5-15 mg/kg, then 0.5-5 mg/kg/hr
                        • Target: EEG burst suppression or seizure cessation
                        • Maintain 24-48 hours, then slow wean with EEG
                        1. ⚠

                           Warning

                           Super-Refractory SE

                           Continues ≥24h despite anesthetic therapy

                           • Ketamine infusion
                           • Immunotherapy if autoimmune suspected
                           • Hypothermia protocol consideration
                           • Epilepsy surgery consultation
                           • Ketogenic diet in select cases
                           1. ✓

                              Outcome

                              Poor Prognosis

                              Prolonged SE associated with high morbidity/mortality