Skip to Main Content

++

  • Seizures persisting for more than 5 minutes, or seizure occurring during the postictal state from a prior seizure
  • Can be convulsive, non-convulsive, and/or refractory (continuing despite two intravenous agents)
  • Etiologies:
    • Known seizure disorder: poor compliance, drug interaction, lack of sleep
    • First seizure:
      • CVA, brain abscess or tumor, meningitis, head trauma
      • Metabolic (hypoglycemia, hyponatremia, hypocalcemia, porphyria)
      • Withdrawal (alcohol or drug), toxic (antidepressants, salicylates, ethylene glycol)

++

ABCs as needed, supplemental oxygen

++

Do not use bicarb to correct metabolic acidosis unless extreme (pH ≤ 6.9).

++

  • Is there a history of epilepsy? Is the patient on anti-epileptics? (Dose, obtain plasma levels)
  • Time of onset (when was the patient last seen normal?)
  • Drugs (agents that lower the seizure threshold; illicit drug abuse?)
  • Mental status (if not awake without twitches for more than 30 minutes, get EEG to rule out non-convulsive status; get CT-scan to rule out evolving brain lesion such as a stroke or hemorrhage)
  • Check for focal neurologic findings (if present, suggest underlying focal lesion)

++

  • Epilepsy or neurology consult
  • EEG – arrange for continuous monitoring if available
  • Call CT scanner and request a STAT head CT w/o (and possibly with, depending on clinical picture and suspicion of other lesion) contrast

++

CBC, electrolytes, liver function panel, urinary toxicology screen, anti-epileptic drug levels, PT/INR, PTT

++

LP if immunosuppressed, fever, or no etiology found

++

PRIMARY:

++

  • Thiamine 100 mg IV
  • 50 mL of D50 IV, unless finger stick >60
  • Lorazepam (Ativan) 0.1 mg/kg IV over 2 minutes (can repeat three times q5 minutes) OR 20 mg PR (if no IV access; can also use nasal midazolam 0.1–0.5 mg/kg) and Fosphenytoin (Cerebyx) 20 mg/kg IV (maximum of 150 mg/min) OR phenytoin (Dilantin) 20 mg/kg IV (maximum of 50 mg/min)
  • If Dilantin allergy, give valproic acid (Depacon) 20 mg/kg IV

++

SECONDARY: (if seizures persist, give one of the following)

++

  • Fosphenytoin (Cerebyx) 10 mg/kg IV (additional)
  • Valproic acid (Depacon) 40 mg/kg IV over 15 minutes
  • Levetiracetam (Keppra) 1000 mg IV (can repeat up to a maximum of 4000 mg)
  • Phenobarbital 20 mg/kg IV (maximum of 100 mg/min)

++

TERTIARY: (if seizures persist, intubate the patient, if not already done, and treat with one of the following)

++

  • Midazolam (Versed): load 0.2 mg/kg IV (maximum 2 mg/kg), then continuous drip 0.5–2.0 mg/kg/h
  • Propofol (Diprivan): load 1 mg/kg IV (maximum 15 mg/kg, avoid >5 mg/kg for >24 hours), then continuous drip 1–15 mg/kg/h
  • Titrate agents towards maximum until seizure cessation or EEG burst-suppression pattern

++

QUATERNARY: (if seizures persist clinically or on EEG)

++

  • Pentobarbital (Nembutal): load 5 mg/kg IV (maximum 10 mg/kg/h), then continuous drip 0.5–10 mg/kg/h

1. Prasad K, Al-Roomi K, Krishnan PR, et al. Anticonvulsant therapy for status epilepticus. Cochrane Database Syst Rev. 2005 Oct;(4):CD003723.   [PubMed: 16235337]
2. Treiman DM, Meyers PF, Walton ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.