Step 1 (0–5 minutes)
Assess airway, apply oxygen and pulse oximetry Begin cardiac telemetry and hemodynamic monitoring Venipuncture to secure access with 2 large-gauge intravenous catheters Stat blood work: basic metabolic panel, liver function tests, calcium, magnesium, phosphate, complete blood count, toxicology screens, troponin, arterial blood gas, and antiepileptic drug levels if appropriate Check finger-stick glucose Begin normal saline drip
Step 2 (6–10 minutes)
Administer 100 mg thiamine IV Administer 50 mL of 50% dextrose IV if hypoglycemic, but withhold if normoglycemic Administer 0.1 mg/kg IV lorazepam (< 2 mg/min)
○ If seizures persist, may repeat initial dose of lorazepam once ○ Beware of sedation, respiratory depression, and hypotension
If no IV access, consider rectal diazepam 10–20 mg
○ If seizures persist, may repeat initial dose of diazepam once ○ Beware of sedation, respiratory depression, and hypotension
Step 3 (11 to 30 minutes)
Administer 20 mg PE/kg IV fosphenytoin (< 150 mg PE/min) or IV 20 mg/kg phenytoin by slow push (< 50 mg/min)
○ Fosphenytoin
■ Beware of cardiac depression and arrhythmia, hypotension, parasthesias, and pruritis ■ Fosphenytoin is more expensive but can be infused at a faster rate, has a lower risk of peripheral infusion-site complications, and is compatible with glucose-containing IV fluids
○ Phenytoin
■ Beware of cardiac depression and arrhythmia, hypotension, infusion site soft tissue, and vascular injury (“purple-glove syndrome”) ■ Incompatible with glucose-containing solutions
Monitor respiratory status, cardiac rhythm, and blood pressure and be prepared to adjust dosages and rates accordingly If seizures persist, give additional IV fosphenytoin or phenytoin to a maximum total dose of 30 mg/kg
Step 4 (31–50 minutes)
If seizures persist, order urgent EEG and neurologic consultation and transfer patient to intensive care unit Initiate intubation before using an anesthetic agent Consider using one of the following:
○ IV phenobarbital 20 mg/kg slow push (< 100 mg/min)
■ Then continuous infusion at 1 mg/kg/h to 4 mg/kg/h ■ Beware of respiratory and cardiac depression, prolonged sedation, allergy, and blood dyscrasias ■ Contraindicated in severe liver dysfunction
○ IV pentobarbital 5 mg/kg (< 50 mg/min)
■ Then continuous infusion at 0.5 mg/kg/h to 5 mg/kg/h ■ Beware of respiratory depression, sedation, and hypotension
○ IV midazolam 0.2 mg/kg (given over 20–30 seconds)
■ Dose may be repeated in 5 minutes if seizures persist ■ Then continuous infusion at 0.05 mg/kg/h to 2.0 mg/kg/h ■ Beware of respiratory depression, sedation, and hypotension
○ IV propofol 1 mg/kg bolus
■ May give repeated boluses every 3–5 minutes to a maximum dose of 10 mg/kg ■ Beware of sedation, hypotension, bradycardia, allergic reaction, and “propofol infusion syndrome” at high doses (metabolic acidosis, cardiac failure with dysrhythmia, rhabdomyolysis, hyperkalemia, and lipemia) ■ Monitor acid base status ■ Continuous infusion involves a large lipid and caloric load
Non-sedating alternatives include:
○ IV valproate bolus of 25 mg/kg to 30 mg/kg (< 3 mg/kg/min)
■ Not FDA approved for SE ■ May be useful in patients who are awake, patients with primary generalized epilepsy, or in situations where intubation is to be avoided ■ Beware of dizziness, hyperammonemia, hypotension, hepatotoxicity, thrombocytopenia, and pancreatitis ■ Contraindicated in severe liver dysfunction, thrombocytopenia, and active bleeding ■ Monitor liver profile, amylase, lipase, and complete blood cell count
○ IV levetiracetam 20 mg/kg over 15 minutes
■ Not FDA approved for SE ■ May be useful in patients who are awake, patients with primary generalized epilepsy, patients with liver disease, or situations in which intubation is to be avoided ■ Beware of neuropsychiatric side effects ■ Dose must be lowered in those with impaired creatinine clearance
Step 5
If seizures persist, maintain continuous IV infusion of anesthetic agents and titrate dose to desired level of EEG suppression-burst as determined by the neurology consultant Defer to neurology consultant for choice of maintenance antiepileptic drug and appropriate dosing
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