Table 3 Pharmacotherapy of generalised convulsive and refractory status epilepticus.
| Drug | Timing | Route | Loading dose | Maximal rate of administration | Maintenance dose | Parameters to monitor |
|---|---|---|---|---|---|---|
| Generalised convulsive status epilepticus | ||||||
| Lorazepam | Within the first 5–10 min of admission or as prehospital treatment | IV bolus | 0.1 mg/kg | 2 mg/min | – | Respiration; blood pressure; consciousness level |
| Diazepam | Within the first 5–10 min, as an alternative to lorazepam; or as pre‐hospital treatment | IV bolus, rectal administration if IV access is not available | 0.2 mg/kg (IV); 10–30 mg (rectal) | 5 mg/min | – | Same as for lorazepam |
| Phenytoin | 10–45 min | IV infusion | 20 mg/kg | 50 mg/min; maximal loading dose 30 mg/kg | 5 mg/kg/day in three divided doses IV | Blood pressure; ECG; watch for purple glove syndrome; avoid glucose‐containing fluids for dilution |
| Fosphenytoin | As an alternative to phenytoin | IV infusion | 20 mg/kg PE | 150 mg/min | 5 mg/kg/day PE IV or IM | Same as for phenytoin; except can be given with glucose‐containing fluids |
| Refractory status epilepticus | ||||||
| Phenobarbital | 45–60 min | IV infusion | 10–20 mg/kg | 100 mg/min | 1–4 mg/kg/day | Cardiorespiratory monitoring |
| Valproate | 45–60 min | IV infusion | 20–25 mg/kg | 3 mg/kg/min | 2 mg/kg/h | Liver function test, ammonia, serum amylase, lipase, blood pressure, platelet count |
| Midazolam | >60 minPre‐hospital treatment | IV bolus or infusion; IM or rectal; buccal; intranasal | Initial bolus: 0.15–0.2 mg/kg; 5–10 mg (IM or rectal); 10 mg or 0.5 mg/kg (buccal); 10 mg (intranasal) | Repeat dose 0.2 mg/kg boluses every 5 min until seizures stop (maximum loading dose 2 mg/kg) | Continuous infusion 0.1–0.4 mg/kg/h, dose titration to seizure or EEG suppression or change in vital signs | Cardiorespiratory monitoring, tachyphylaxis with long‐term infusion |
| Propofol | >60 min | IV bolus or infusion | Initial bolus 1 mg/kg | Repeat 1–2 mg/kg boluses every 5 min until seizures stop (maximum loading dose: 10 mg/kg) | Continuous infusion 1–12 mg/kg/h, for dose titration as for midazolam | Arterial blood gases, blood pressure, (propofol infusion syndrome) lipids, rebound seizures with rapid withdrawal |
| Pentobarbital | >60 min | IV bolus or infusion | Initial bolus 5 mg/kg | Repeat 5 mg/kg boluses until seizures stop (maximum bolus rate: 50 mg/min), dose titration to change in blood pressure | Continuous infusion: 0.5–10 mg/kg/h, for dose titration as for midazolam | Cardiorespiratory monitoring |
| Thiopental | >60 min | IV bolus or infusion | Initial bolus 100–250 mg over 20 s | Repeat 50 mg boluses every 2–3 min until seizures stop, dose titration to change in blood pressure | Continuous infusion 3–5 mg/kg/h, for dose titration as for midazolam | Cardiorespiratory monitoring, prolonged coma, laryngospasm, spasm at injection site, avoid plastic‐giving sets and exposure to air |
| Isoflurane | >60 min | Inhalation | End tidal concentration of 0.8–2% | Dose tailored to cardiorespiratory monitoring | For dose titration as for midazolam | Cardiorespiratory monitoring, administration requires anaesthetic system with a scavenging apparatus |
ECG, electrocardiogram, EEG, electroencephalographic; IM, intramuscular; IV, intravenous; PE, phenytoin equivalent.