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Convulsive Status Epilepticus Treatment

 The proposed treatment algorithm for status epilepticus (seizures greater than 30 minutes duration) in children and adults was developed by a literature review. Initiate treatment for seizures of greater than 5 minute duration as there is a greater likelihood of seizures progressing to status epilepticus when a seizure goes beyond 5 minutes:

First-Line Therapy (first 5 to 20 minutes of continued seizures): Choose One of the following options
  • IM midazolam as a single dose OR
  • IV LORazepam, may repeat with one dose OR
  • IV diazepam, may repeat with one dose

Alternatives, if none of the above are available:
IV PHENobarbital as a single dose; OR rectal diazepam as a single dose; OR intranasal midazolam; OR buccal midazolam
Effectiveness between IV LORazepam and IV diazepam was similar. Midazolam by IM, intranasal, or buccal may be more effective than diazepam IV or rectal.

Second-Line Therapy (20 to 40 minutes of continued seizures) based on expert opinion: Choose One of the following options
  • IV fosphenytoin as a single dose (IV phenytoin is an acceptable alternative)
  • IV valproic acid as a single dose
  • IV levETIRAcetam as a single dose

Alternative, if none of the above are available:
IV PHENobarbital (if not already administered)

Third-Line Therapy (40 minutes or more of seizures)
No data to provide definitive recommendations. May repeat second-line therapy or use anesthetic doses of thiopental, midazolam, PENTobarbital, or propofol while continuously monitoring EEG

 - Glauser T, Shinnar S, Gloss D et al: Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr Jan, 2016; 16(1): 48-61.