Patient Information

🚨 Treatment Algorithm

CRITICAL: Status epilepticus is defined as ≥5 minutes of continuous seizure activity. Immediate treatment is essential - efficacy decreases rapidly with time!

🔴 PHASE 1: Immediate Stabilization (0-5 minutes)

ABCs First: Airway, Breathing, Circulation. Position patient, suction if needed, O2, IV access, monitor vitals.
FIRST-LINE: Benzodiazepines
Choose ONE of the following:
Lorazepam (PREFERRED if IV access available):
Weight: kg
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Dose: 0.1 mg/kg IV (typical adult dose: 4-8 mg). Max rate: 2 mg/min. May repeat once after 5 minutes if seizures continue.
Midazolam (if NO IV access):
10 mg IM (or 0.2 mg/kg, max 10 mg)
Faster than getting IV access. Onset 5-10 minutes. May repeat once.
Diazepam (alternative):
Weight: kg
Enter weight to calculate dose
Dose: 0.15 mg/kg IV (typical: 5-10 mg). Shorter duration of action than lorazepam.

🟡 PHASE 2: Second-Line Therapy (5-20 minutes)

If seizures continue after adequate benzodiazepine dose, proceed immediately to second-line agent. Don't wait!
Levetiracetam
Weight: kg
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Dose: 60 mg/kg IV (max 4500 mg). Infuse over 5-10 minutes. Excellent safety profile, minimal drug interactions.
Fosphenytoin
Weight: kg
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Dose: 20 mg PE/kg IV (max 1500 mg PE). Max rate: 150 mg PE/min. Requires close monitoring of BP/HR/O2 as it can cause hypotension. Hypotension is not a contraindication as long as IV access and pressors are available. Use recommended infusion rates.
Valproate
Weight: kg
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Dose: 40 mg/kg IV (max 3000 mg). Infuse over 10 minutes. Avoid in pregnancy or known significant liver/mitochondrial disease. Maintenance dose may need adjustment later for hepatic insufficiency.
Lacosamide
Weight: kg
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Dose: 6-8 mg/kg IV (typical: 200-400 mg). Infuse over 15-30 minutes. Check baseline ECG for PR interval; use with caution if prolonged.

🛡️ Intubation Criteria

Consider intubation if ANY of the following:
  • Refractory status epilepticus (failed 2 appropriate medications)
  • Respiratory depression or failure (RR <10, SpO2 <90%)
  • Airway compromise or inability to protect airway
  • Hemodynamic instability
  • Concern for elevated intracranial pressure
  • Need for continuous anesthetic infusions
RSI Considerations: Use propofol (anti-seizure properties) or ketamine (1 mg/kg). Avoid succinylcholine if SE >30 minutes (hyperkalemia risk). Consider rocuronium with sugammadex reversal for neuro exam.

🔴 PHASE 3: Refractory SE (20+ minutes)

REFRACTORY STATUS EPILEPTICUS - Seizures persisting despite adequate doses of benzodiazepine + second-line ASM. Consider intubation and anesthetic agents. Continuous EEG (cEEG) is required to guide therapy.
Ketamine (Emerging first choice)
Weight: kg
Enter weight to calculate dose
Dose: 1-2 mg/kg IV bolus, then 1-5 mg/kg/hr infusion. May avoid intubation. Hemodynamically stable. Often given concurrently with a midazolam infusion.
Propofol
1-2 mg/kg IV bolus, then 2-10 mg/kg/hr infusion
Requires intubation. Risk of propofol infusion syndrome with high doses. Monitor lactate, lipids. Consider triglyceride monitoring.
Midazolam infusion
0.2 mg/kg IV bolus, then 0.05-2 mg/kg/hr infusion
Less hypotension than propofol. Good option for hemodynamically unstable patients.
Pentobarbital
Load: 5-15 mg/kg IV, then infusion: 0.5-5 mg/kg/hr
Induces therapeutic coma. Long half-life. High risk of respiratory depression and hypotension; requires intubation and pressor support. Titrate to burst-suppression on cEEG.

⚫ PHASE 4: Super-Refractory SE (24+ hours)

SUPER-REFRACTORY SE - Persisting despite 24+ hours of anesthesia or recurring during anesthetic wean. Requires specialist neurology consultation.
Consider Additional Therapies
• Therapeutic hypothermia (experimental)
• High-dose barbiturate coma
• Inhaled anesthetics
• Immunotherapy if autoimmune suspected
• Surgical evaluation for focal lesions
• Continuous EEG monitoring essential
💊 Key Principles:
  • Early treatment is crucial - don't delay
  • Use adequate doses - underdosing is common and harmful
  • Always load maintenance ASM even if benzodiazepines work
  • Consider reversible causes: glucose, thiamine, infection, medication compliance
  • Continuous EEG monitoring for intubated patients
  • Avoid paralysis without EEG monitoring