Status Epilepticus: When Minutes Count
- Sara Gray
- May 26
- 4 min read
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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