Michael Poon's Shrine of Neurology

Time (min)

Action

0 - 5 min

Diagnose status epilepticus by observing continued seizure activity or one additional seizure.
Give oxygen by nasal cannula or mask; position patient's head for optimal airway patency; consider intubation if respiratory assistance is needed.
Obtain and record vital signs at onset and periodically thereafter; correct any abnormalities as necessary; initiate ECG monitoring.
Establish IV access; draw venous blood samples for glucose level, serum chemistries, hematology studies, toxicology screen and determination of antiepileptic levels.
Assess oxygenation with oximetry or periodic arterial blood gas determinations.

6 - 9 min

If hypoglycemia is established or blood glucose is available, administer glucose; in adults, give 100 mg of thiamine first, followed by 50 ml of 50% glucose by direct IV push; in children, the dose of glucose is 2 ml/kg of 25% glucose.

10 - 60 min

Administer either 0.1 mg/kg of lorazepam at 2 mg/min (maximum dose of 8mg) or 0.2mg/kg of diazepam at 5 mg/min by IV; if diazepam is used, it may be repeated if seizures do not stop after 5 min. For all patients given diazepam and for patients who continue to seize after lorazepam, administer by IV 15-20 mg/kg phenytoin equivalent of fosphenytoin no faster than 150 mg phenytoin equivalent/min in adults or 3 mg phenytoin equivalent/kg/min in children; monitor ECG and blood pressure during infusion. For patients who stop seizing after lorazepam, administer 15-20 mg/kg phenytoin equivalent of fosphenytoin at a slower infusion rate (e.g., 50 mg phenytoin equivalent/min).

>60 min

If status does not stop after 20 mg/kg phenytoin equivalent of fosphenytoin, give additional doses of 5 mg phenytoin equivalent/kg to a maximum dose of 30 mg phenytoin equivalent/kg. If status persists, give 20 mg/kg of phenobarbital by IV at 100 mg/min; when phenobarbital is given after benzodiazepine, the risk of apnea or hypopnea is great and assisted ventilatoin is usually required. If status persists, give anesthetic doses of drugs such as pentobarbital; ventilatory assitance and vasopressors are virtually always necessary.