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Mx of status epilepticus

basic life support

  • oxygen
  • protect airway
  • exclude hypoglycaemia early!
  • iv access - consider bloods for U&E, Ca, PO4, glucose, and anticonvulsant levels if already on them
  • cardiac monitor and oxygen saturation monitor when possible - usually after initial dose of 1st line anticonvulsant
  • think about possible causes whilst resuscitation in progress (see below), in particular:
    • if hypoglycaemic, give iv glucose
    • if pregnant then consider eclampsia and magnesium Rx
    • drug-induced seizures may warrant different Rx or earlier intubation
    • not enough oxygen to brain will cause seizures - could it be secondary to hypoxia or hypotension?
    • Is it really epilepsy? - could it be pseudo-seizures - consider serum prolactin
    • if known to have severe hyponatraemia < 120mEq/L - give 3% saline boluses

1st line anticonvulsants if seizure lasts > 5 minutes or is unwitnessed onset


  • midazolam 0.15-0.3 mg/kg IM (or intranasally or 0.5mg/kg (max. 10mg) buccal) or diazepam 0.4 mg/kg rectally (max 10mg)

in hospital

2nd line

  • if still convulsing after further 5-10min then start either:
      • phenytoin 18 mg/kg (max. 1.2g) IV via syringe pump over 45-60min with 0.22 micron filter
        • max. infusion rate = 50 mg/min
        • can also be given via IMED diluted in 0.9% saline
        • NOT compatible with benzodiazepines or dextrose in same iv line
        • avoid in juvenile myoclonic epilepsy (JME)
    • iv phenobarbitone 20 mg/kg at 100 mg/min.
    • iv levetiracetam (Keppra) 25mg/kg (usually 1g in adults) over 15 min
      • although not well studies, appears to be as effective as phenytoin but without the iv line incompatibility issues but may not be as effective as sodium valproate (Epilim) as a 2nd line for status
    • iv sodium valproate (Epilim) 20-40mg/kg load dose given at 5mg/kg/min in adults
      • may be preferred as a non-sedating option for focal or myoclonic status, and is preferred over phenytoin for primary generalized epilepsies
      • may need higher dose if patient has been on enzyme inducing anticonvulsants
      • BUT risk of hepatic dysfunction and coagulopathy are important considerations in patients with active bleeding or those with liver disease or aminoacidopathies
  • consider aetiology and possible specific therapies (see below)

3rd line

  • consider pyridoxine (100mg IV) in young infants with seizures refractory to standard anticonvulsants.
  • consider more phenytoin to 30mg/kg total dose if not C/I
  • consider more midazolam
    • in children, if 2 appropriate doses fail to terminate the seizure, further doses are unlikely to be effective and increase the risk of respiratory depression.
    • midazolam infusion 1 - 5 mcg/kg/min might be an alternative to RSI intubation with supervision by senior staff.
  • rapid sequence induction (RSI) for emergency intubation intubation with induction dose then infusion of either:

consider aetiology

1st seizure in the adult patient

  • refer to 1st seizure clinic
  • refer to EEG (form in SH EOU “forms” folder)
  • refer for MRI scan

other resources

seizures.txt · Last modified: 2022/05/03 07:08 by gary1

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