American Epilepsy Society issues guideline and treatment algorithm for convulsive status epilepticus. The guideline was endorsed by the Epilepsy Foundation, Child Neurology Society, and American College of Emergency Physicians.

Status epilepticus – continuous or rapid sequential seizure activity for 30 minutes or more – is a medical emergency with a high mortality rate in both children and adults. Prompt and effective treatment is the key.

This guideline focuses on convulsive status epilepticus in particular because it is the most common type of status epilepticus and is associated with substantial mortality.

“The goal of therapy is the rapid termination of the seizure activity to reduce neurological injuries and deaths.”

The guideline, which reviewed all available adult and pediatric evidence, provides a treatment algorithm that comprises three phases of treatment.

• Stabilization phase (0-5 minutes of seizure activity), includes standard initial first aid for seizures and initial assessments and monitoring.
• Initial therapy phase (5-20 minutes of seizure activity) when it is clear the seizure requires medical intervention, a benzodiazepine (specifically IM midazolam, IV lorazepam, or IV diazepam) is recommended as the initial therapy of choice, given its demonstrated efficacy, safety, and tolerability.
• Second therapy phase (20-40 minutes of seizure activity) when response (or lack of response) to the initial therapy should be apparent. Reasonable options include fosphenytoin, valproic acid and levetiracetam.

There is no clear evidence that any one of these options is better than the others. Because of adverse events, IV phenobarbital is a reasonable second-therapy alternative if none of the three recommended therapies is available.

• Third therapy phase (40+minutes of seizure activity). There is no clear evidence to guide therapy in this phase. The guideline found strong evidence that initial second therapy is often less effective than initial therapy, and the third therapy is substantially less effective than initial therapy.

Thus, if second therapy fails to stop the seizures, treatment considerations should include repeating second-line therapy or anesthetic doses of either thiopental, midazolam, pentobarbital, or propofol (all with continuous EEG monitoring).

The guideline also found evidence that depending on the causes or severity of the seizure, clinicians may go through the phases faster or even skip the second phase and move rapidly to the third phase, especially in sick or intensive care unit patients.

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