Epilepsy Service at MassGeneral Hospital

STATUS EPILEPTICUS PROTOCOL

Status Epilepticus is a medical emergency. Outcome correlates with rapidity of treatment and response, and with underlying etiology. Protocols provide a useful outline and checklist for treating physicians, and outcomes have been shown to be better in centers that utilize written protocols for evaluation and treatment. All protocols, however, should be used with caution and modified as clinical circumstances dictate.


 

INTERVENTIONS

Check as completed

TIME

0 - 30 Minutes

 

 

 

 Initial rapid assessment: Airway, Breathing, Circulation

 

0 min.

 Record Vital Signs

 

1 min

 

 

 

 Monitor: O2 SATURATION, EKG

 

2 min.

 

 

 

 Establish IV access and have bloods sent:

 

2  -10 min.

            CBC, Lytes, BUN/Cr, Glucose, Ca, Mg, P04, LFTS, AED levels, Toxicology screen, ABG.

 

 

 

 

 

 THIAMINE, 100 MG IV

 

5-10 min.

 50% DEXTROSE, 50 CC IV

 

 

 

 

 

LORAZEPAM, 0.1 MG/KG IV (<2 MG/MIN.)

 

5-10 min.

 

 

 

FOSPHENYTOIN, 20 MG/KG IV (150 MG/MIN.) or PHENYTOIN (20 MG/KG @ 50 MG/MIN)

 

10-20 min.

            Begin concurrently with benzodiazepine (above)

 

 

            Monitor EKG, Check BP Q 120 sec

 

.

 

 

 

FOSPHENYTOIN,  ADDITIONAL 10 MG/KG IV (150 MG/min.) or PHENYTOIN (10 MG/KG @ 50 MG/MIN)

 

30 - 40 min.

            Monitor EKG, Check BP Q 60 sec

 

 

     
May use VALPROIC ACID (DEPACON) 30 MG/KG IV (150 MG/min.) or LEVETIRACETAM (KEPPRA) 50 MG/KG IV (100 mg/min) as alternatives when FOSPHENYTOIN or PHENYTOIN is contraindicated. See references below.    
     

30 – 60 Minutes

            Send repeat Phenytoin level -20 min. after load

 

 

 

 

 

PHENOBARBITAL 20 MG/KG (75 mg/min)

 

40 min

INTUBATE (If not done previously)

 

50 min.

INITIATE EEG MONITORING

 

 

 

 

 

Contact Neurologist/Epilepsy Specialist

MGH Epilepsy Service: 617 726-3311

 

 

 

Options for next step include:

 

 

> 60 Minutes

 

 

 

 MIDAZOLAM 0.2 MG/KG IV (loading dose) (Preferred if BP is unstable)

 

50-60 min.

            Titrate dose (0.1-0.4 mg/kg/hr) to stop electrographic and clinical seizures

 

 

            Use fluid or pressor to support BP if needed.

 

 

             

 

 

OR

 

 

PENTOBARBITAL, 5 MG/KG IV
           (loading dose) to obtain burst suppression on EEG.

 

50-60 min.

            Titrate dose (0.3-9 mg/kg/hr, avg=4 mg/kg/hr) to maintain burst suppression on EEG.

 

 

            Use fluid to support BP if needed, add pressor only if fluid fails or not clinically advisable.

 

 

OR

 

 

PROPOFOL, 1-2 mg/kg load, 2-10 mg/kg/hr maintenance drip to stop clinical and EEG seizures or maintain burst suppression on EEG.
             

 

50-60 min.

 

 

 

OBTAIN CT SCAN (If clinically indicated)

 

 

Correct underlying cause of Status Epilepticus

 

3-48 hours

Adjust the principal anticonvulsants to therapeutic effect

 

24 hours

Taper Midazolam, Pentobarbital or Propofol after above complete

 

24-48 hours

CONCURRENT EVALUATIONS (Beginning at the onset of management)

History, Exam, check labs:      
STAT Head CT  (MGH: 6-6760  BWH: 7213)              
Cool patient if febrile
Consider Antibiotics & LP, especially if febrile or not known epileptic

Notes

Potential indications for urgent EEG or continuous EEG monitoring:

Question of non-epileptic status (pseudo-status)

  • Question of absence vs. complex partial status epilepticus
  • Failure to regain normal consciousness within a reasonable time after apparent cessation of seizure activity
  • Monitoring of anesthetic suppression of epileptic activity (burst-suppression interval)
  • All requests for urgent EEG and monitoring should be discussed with Epilepsy Fellow on call (Page through Partners or 726-3311).

REFERENCES:

Safety and pharmacokinetics of intravenous levetiracetam infusion as add-on in status epilepticus.

Uges JW, van Huizen MD, Engelsman J, Wilms EB, Touw DJ, Peeters E, Vecht CJ.

Epilepsia. 2009 Mar;50(3):415-21. Epub 2008 Nov 17.

PMID: 19054418

 

Sodium valproate vs phenytoin in status epilepticus: a pilot study.

Misra UK, Kalita J, Patel R.

Neurology. 2006 Jul 25;67(2):340-2.

PMID: 16864836

Last Modified 7/6/09

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