Status Epilepticus: When Minutes Count

Dr. Sara Gray

In status epilepticus, every minute matters. Earlier recognition and timely treatment are critical to improving outcomes and reducing mortality.

🔍 Key Learning Points:

1. Redefining the Clock:

• The threshold for defining status epilepticus (SE) has shortened over time.

  
  

  • Generalized seizures: status at 5 minutes

  • Focal, absence, or non-convulsive seizures: status at 10 minutes

    
    

2. Status Epilepticus Carries High Risk:

• In-hospital mortality ranges from 17–40%

• ~30% of patients will suffer a new moderate-to-severe neurologic deficit

3. Outcomes Worsen With:

• Prolonged seizure duration

• Delayed administration of first-line treatment

• Inadequate initial dosing

4. First-Line Treatment = Benzodiazepines:

• Lorazepam

  
  

  • Pediatrics: 0.1 mg/kg IV

  • Adults: 2–4 mg IV

  
  

• Midazolam

  
  

  • Pediatrics: 0.2 mg/kg IV/IM/IN

  • Adults: 5–10 mg IV/IM/IN

    
    

5. Second-Line Treatment Options:

• Levetiracetam (preferred for rapid infusion): 60 mg/kg IV over 5 mins (max 4.5g)

• Phenytoin: 20 mg/kg IV over 20 mins

• Other options: Valproic acid, Lacosamide

6. Third-Line: Sedation and Intubation

• Dr. Gray prefers propofol

• Debate persists on the use of paralytics—no clear evidence favors one approach

  
  

  • Options: rocuronium (± sugammadex), succinylcholine, none, or even tourniquet technique

7. Benzodiazepine Resistance:

• Occurs in 1/3 of refractory SE cases

• Increases with seizure duration

• Consider ketamine or phenobarbital in these scenarios

8. The Future: ED EEG

• Bedside EEG, possibly enhanced by AI interpretation, is on the horizon

• Could significantly enhance diagnosis and management of non-convulsive SE in the ED

Status epilepticus is a time-critical neurologic emergency. Know the definitions. Act early. Dose right. And prepare for the next frontier—point-of-care EEG.

References

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Roberg LE, Monsson O, Kristensen SB, et al. Prediction of Long-term Survival After Status Epilepticus Using the ACD Score. JAMA Neurol. 2022;79(6):604–613. doi:10.1001/jamaneurol.2022.0609

Ascoli, M., Ferlazzo, E., Gasparini, S., et al. (2021). Epidemiology and Outcomes of Status Epilepticus. International Journal of General Medicine, 14, 2965–2973. https://doi.org/10.2147/IJGM.S295855

Drislane  FW, Blum  AS, Lopez  MR, Gautam  S, Schomer  DL.  Duration of refractory status epilepticus and outcome: loss of prognostic utility after several hours.   Epilepsia. 2009;50(6):1566-1571. doi:10.1111/j.1528-1167.2008.01993.x

Madžar  D, Geyer  A, Knappe  RU,  et al.  Association of seizure duration and outcome in refractory status epilepticus.   J Neurol. 2016;263(3):485-491. doi:10.1007/s00415-015-7992-0

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Legriel  S, Azoulay  E, Resche-Rigon  M,  et al.  Functional outcome after convulsive status epilepticus.   Crit Care Med. 2010;38(12):2295-2303. doi:10.1097/CCM.0b013e3181f859a6

Gaínza-Lein  M, Sánchez Fernández  I, Jackson  M,  et al; Pediatric Status Epilepticus Research Group.  Association of time to treatment with short-term outcomes for pediatric patients with refractory convulsive status epilepticus.   JAMA Neurol. 2018;75(4):410-418. doi:10.1001/jamaneurol.2017.4382

Kellinghaus  C, Rossetti  AO, Trinka  E,  et al.  Factors predicting cessation of status epilepticus in clinical practice: data from a prospective observational registry (SENSE).   Ann Neurol. 2019;85(3):421-432.

Alkazemi, Afrah1; Schontz, Michael1; Chan, Michael G2; McLaughlin, Kevin1; Anger, Kevin1; Szumita, Paul2. 17: Safety of Intravenous Push Levetiracetam Administration at a Tertiary Academic Medical Center. Critical Care Medicine 49(1):p 9, January 2021. | DOI: 10.1097/01.ccm.0000726096.28866.03

Jense A, Douville A, Weiss A. The safety of rapid infusion levetiracetam: A systematic review. Pharmacotherapy. 2022 Jun;42(6):495-503. doi: 10.1002/phar.2687. Epub 2022 May 13. PMID: 35502462.

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Lattanzi S, Leitinger M, Rocchi C, et al. Unraveling the enigma of new-onset refractory status epilepticus: a systematic review of aetiologies. Eur J Neurol. 2022; 29: 626- 647. https://doi.org/10.1111/ene.15149

R Wickstrom, O Taraschenko, R Dilena, et al, the International NORSE Consensus Group. International consensus recommendations for management of new onset refractory status epilepticus including febrile infection-related epilepsy syndrome: Statements and supporting evidence. Epilepsia 2022.

Burman, R.J., Rosch, R.E., Wilmshurst, J.M. et al. Why won’t it stop? The dynamics of benzodiazepine resistance in status epilepticus. Nat Rev Neurol 18, 428–441 (2022). https://doi.org/10.1038/s41582-022-00664-3

David G. Vossler, Jacquelyn L. Bainbridge, Jane G. Boggs, et al. Treatment of Refractory Convulsive Status Epilepticus: A Comprehensive Review by the American Epilepsy Society Treatments Committee Epilepsy Currents 2020 20:5, 245-264. https://doi.org/10.1177/1535759720928269

Wright NMK, Madill ES, Isenberg D, Gururangan K, McClellen H, Snell S, Jacobson MP, Gentile NT, Govindarajan P. Evaluating the utility of Rapid Response EEG in emergency care. Emerg Med J. 2021 Dec;38(12):923-926. doi: 10.1136/emermed-2020-210903. Epub 2021 May 26. PMID: 34039642.

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Kozak R, Gururangan K, Dorriz PJ, Kaplan M. Point-of-care electroencephalography enables rapid evaluation and management of non-convulsive seizures and status epilepticus in the emergency department. JACEP Open. 2023; 4:e13004. https://doi.org/10.1002/emp2.13004

Tveit J, Aurlien H, Plis S, et al. Automated Interpretation of Clinical Electroencephalograms Using Artificial Intelligence. JAMA Neurol. 2023;80(8):805–812. doi:10.1001/jamaneurol.2023.1645