Skip to Main Content

Chapter 16: Status Epilepticus

An 80-year-old man with a past medical history of epilepsy on home carbamazepine and mild cognitive impairment is witnessed by his wife to have a generalized tonic-clonic seizure at home lasting 25 minutes. Emergency medical services (EMS) arrives on the scene while he is seizing and administers midazolam 10 mg intramuscularly which stops the seizure activity. He is somonolent but opens his eyes to voice, states his name and city, and follows simple commands. In the ED, an initial set of vital signs demonstrates a temperature of 37°C, heart rate (HR) of 108 beats/min, blood pressure (BP) of 130/89 mmHg, respiration rate (RR) of 12 breaths/min, pulse oximetry of 98% on room air, and a fingerstick glucose of 180 mg/dL. He has another GTC seizure lasting 6 minutes. He has IV access; therefore, lorazepam 4 mg IV is administered. This time, he is lethargic, disoriented, and no longer reliably following commands. How would you describe this patient’s problem?

A. An isolated seizure

B. Early status epilepticus

C. Established status epilepticus

D. Refractory status epilepticus

C. Established status epilepticus

He meets definition for generalized convulsive status epilepticus with seizure lasting longer than 5 minutes, so it is not early status epilepticus (choice B); in addition, he has had recurrent seizures without return to baseline. Specifically, this would be considered established status epilepticus because he failed first-line benzodiazepine. He meets criteria for status epilepticus, thus this is not an isolated seizure (choice A). He has not been given and failed a second-line agent, which defines refractory status epilepticus (choice D).

A patient is noted to have status epilepticus. While the lorazepam is being administered, what do you order?

A. Levetiracetam 60 mg/kg IV or 4500 mg max

B. Fosphenytoin 20 mg/kg IV or 1500 mg max

C. Valproic acid 40 mg/kg IV or 3000 mg max

D. Any of the above

D. Any of the above

First-line therapy has failed, and an urgent second-line agent is needed. There is no strong evidence for use of one over another. Levetiracetam, fosphenytoin, and valproic acid are commonly used (choices A–C); lacosamide and perhaps brivatacetam are reasonable options as well. Because of his somnolence, valproic acid or levetiracetam might be better choices in this case. Neither is associated with significant cardiorespiratory depression.

A 71-year-old woman with a medical history of prior nonconvulsive status epilepticus on home lacosamide 100 mg twice ...

Pop-up div Successfully Displayed

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