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CLINICAL PRACTICE PROFESSIONAL GUIDELINE Status Epilepticus and Refractory Status Epilepticus, Management of Adult
TITLE: and Paediatric Patients
DATE OF ISSUE:
ISSUED BY:
SUPERCEDES:
ISSUED BY:
Purpose:
To provide a guideline to assist physicians in the emergency management of patients with acute
status epilepticus and refractory status epilepticus, both adults and paediatrics.

Definition of Status Epilepticus (SE):
Adults
Continuous seizures lasting at least 5 minutes or two or more discrete seizures between which
there is incomplete recovery of consciousness. Serial seizures are two or more seizures occurring
over a relatively brief period (i.e., minutes to many hours), but with the patient regaining
consciousness between the seizures. (1)
Paediatrics
Single generalized (tonic-clonic, myoclonic, tonic, or absence) or focal (clonic or jacksonian) seizure
lasting 30 min or longer; includes any series of seizures without intervening return of consciousness
with duration of greater than 30 min.(2)
Generalized convulsive status includes tonic-clonic, tonic, clonic, or myoclonic SE, although the
majority of cases consist of recurrent tonic-clonic seizures.
Nonconvulsive SE includes absence and complex partial SE, both of which are characterized by
clouding of consciousness with or without minor motor manifestations. With nonconvulsive SE the
patient may appear confused, dazed or unable to speak. The patient may seem to comprehend but
is unable to respond appropriately. The patient may appear to be comatose with or without subtle
convulsive movements such as rhythmic muscle twitches or tonic eye deviation (also cal ed
Subclinical Status). The EEG shows continuous ictal discharges. An EEG is usually required to
distinguish between the two. Any type of simple partial seizure, including seizures with sensory,
motor, language, autonomic, or psychic manifestations, can evolve into SE. (3)
Status Epilepticus and Refractory
Status Epilepticus, Management
of Adult and Paediatric Patients
Definition of Refractory Status Epilepticus (RSE):
Adults
SE that does not respond to a benzodiazepine and phenytoin. (1)
Paediatrics
Persisting seizures. (2)
Etiology of Status Epilepticus in Urban Hospital Practice (4)
Etiology

*may include tricylic antidepressants, cocaine, opiates, ethylene glycol, methanol, phenothiazines,
salicylates, carbon monoxide
**such as bacterial meningitis, viral encephalitis including West Nile
***such as hyponatremia, hypercalcemia, hypocalcemia, hypoglycemia, organ dysfunction such as
hepatic, renal, hypercarbic respiratory failure
Management
Adults

Emergency Management of Acute Status Epilepticus - Adults - see Appendix A
Refractory Status Epilepticus - ICU Management - Adults - see Appendix B
Paediatrics
Emergency Management of Acute Status Epilepticus - Paediatrics - see Appendix C
Evaluation:
Following implementation, a staff survey will be conducted to determine if staff are aware of the guideline. Status Epilepticus and Refractory
Status Epilepticus, Management
of Adult and Paediatric Patients
Approval:
General Medicine Steering Committee - May 19, 2005
ER Steering Committee - June 21, 2005
Paediatrics Steering Committee - ………….
CQCC - June 15, 2005 (FYI)
PPAC - June 27, 2005 (FYI)
MAC - Dec 5, 2005 (FYI)
Developed by:
ER Steering and General Medicine Subcommittee
Leaders - ER physician, Intensivist, Neurologist
Team Members - Neurology Nurse Specialist, General Medicine Quality Facilitator, ICU
Pharmacist, EEG technologist, Psychologist, Paediatrics Nurse Educator, Chief of Paediatrics,
Paediatric Pharmacist, ER Nurse Educator, ER Pharmacist, ICU Nurse Educator
References:
1. Lowenstein DH, Al dredge BK. Status Epilepticus. N Engl J Med 1998; 338: 970-976. 2. Cheng A, Wil iams BA, Sivarajan BV (editors), The Hospital for Sick Children's Handbook of Paediatrics, 10th edition (2003), The Hospital for Sick Children, Toronto, Canada, Elsevier Canada. 3. Goetz, Textbook of Clinical Neurology, 2nd edition, 2003 Elsevier, Chapter Epilepsies and 4. Bassin S, Smith TL, Bleck TP. Clinical review: status epilepticus. Critical Care 2002; 6: 137- 5. Vasile B, Rasulo F, Candiani A, Latronico N. The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome. Intensive Care Med; 29: 1417-1425. 6. Giroud M, Gras D, Escousse A et al. Use of injectable valproic acid in status epilepticus: a pilot study. Drug Invest 1993; 5:154-159. 7. Wheless JW, Vazquez BR, Kanner AM et al. Rapid infusion with valproate sodium is well tolerated in patients with epilepsy. Neurology 2004; 63 (8): 1-5. Appendix A
Emergency Management of Acute Status Epilepticus
(continuous seizures lasting at least 5 min or two or more discrete seizures between which there is incomplete recovery of consciousness) Do stat blood glucose via
NOTE IMPORTANCE OF
AGGRESSIVE,
SIMULTANEOUS PURSUIT
OF ETIOLOGY
EG. LOOK FOR AND TREAT
MENINGITIS/ENCEPHALITIS.
Lorazepam 4 mg IV over 2 minutes
(lorazepam preferred due to long duration of effect and less interference with EEG) Alternative: Give rectally if IV access difficult, unavailable or delayed. *Tests: CBC, lytes, Ca, Mg, albumin (for pts having phenytoin levels measured), blood cultures, urine cultures, urinalysis, antiepileptic drug levels, toxicology screen, (consider Monitoring: VS, neurovitals, cardiac monitor, BP monitor, O2 sat Consider: loading with phenytoin 15-20 mg/kg Give additional lorazepam, up to a total dose of 0.1 mg/kg IV at Monitor: VS, neurovitals, cardiac monitor, O2 sat Adjust: patient's at home antiepileptic Phenytoin 20 mg/kg IV in NS, run at 50 mg/min OR 25 mg/min EEG: prior to discharge if possible or as an for patients with risk of hypotension, with an abnormal preinfusion ECG, with cardiovascular disease or is elderly. Use (For patients compliant with phenytoin at home, use 500 mg IV, Refractory SE
Give additional phenytoin, up to a total dose of 30 mg/kg IV in NS over 15 min then continue maintenance dose of 300 mg/day Neurology/Medicine/ICU consult, intubation, **EEG** 1. Lowenstein DH, Alldredge BK. Status Epilepticus. N Engl J Med 1998; 338: 970-976. Appendix B
Refractory Status Epilepticus - ICU Management
(Status epilepticus that does not respond to a benzodiazepine and phenytoin) Intubate and ventilate patient, admit to ICU Note importance of aggressive, simultaneous pursuit of etiology eg. look for and treat meningitis/encephalitis. Use IV fluids and low-dose dopamine to treat hypotension. If necessary, add low-dose dobutamine. Decrease dosage of midazolam or propofol if there are any signs of cardiovascular compromise. Start first:
Midazolam
Give 4 to 10 mg as slow IV bolus, then initiate IV Phenobarbital
infusion at 2 mg/h. Titrate up to 25 mg/h. Continue maintenance doses of Phenobarbital and Phenytoin. ALTERNATIVE:
Propofol
Give 1-2 mg/kg as slow IV bolus, then initiate IV infusion at 2 mg/kg/h, titrate to a maximum of 5 mg/kg/h. (If > 5 mg/kg/h required, avoid infusion >48 h) 5 Continue maintenance doses of Phenobarbital and and prior to discharge: - consult neuropsychology - notify Ministry of Transport Consider addition of Pentobarbital (Nembutal)* 10-15 mg/kg IV over 1 h then 0.5-1 mg/kg/h Valproic acid* may be considered. Give 15 mg/kg IV bolus (in 25 mL NS over 5 min) then 30 min following bolus, start 1 mg/kg/h IV infusion (6,7) Consider surgical options, contact Toronto 1. Lowenstein DH, Alldredge BK. Status Epilepticus. N Engl J Med 1998; 338: 970-976. 5. Vasile B, Rasulo F, Candiani A, Latronico N. The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome. Intensive Care Med; 29: 1417-1425. 6. Giroud M, Gras D, Escousse A et al. Use of injectable valproic acid in status epilepticus: a pilot study. Drug 7. Wheless JW, Vazquez BR, Kanner AM et al. Rapid infusion with valproate sodium is well tolerated in patients with epilepsy. Neurology 2004; 63 (8): 1-5. Appendix C
Emergency Management of Acute Status Epilepticus
PAEDIATRICS
(single generalized (tonic-clonic, myoclonic, tonic or absence) or focal (clonic or jacksonian) seizure lasting longer than 30 min or longer; includes any series of seizures without intervening return of consciousness with duration of greater than 30 min) 3. Establish two IVs,
Do stat blood glucose via
glucometer and obtain labwork*
NOTE IMPORTANCE OF
AGGRESSIVE,
Administer: 5-10 mL/kg of D10W or D10 NS SIMULTANEOUS PURSUIT
OF ETIOLOGY
EG. LOOK FOR AND TREAT
MENINGITIS/ENCEPHALITIS.
Lorazepam 0.1 mg/kg IV (max 4 mg/dose); repeat q5-10 min prn to max of two doses. Max rate: 2 mg/min; push slowly over 5 min
(lorazepam preferred due to long duration of effect and less interference with EEG) Alternative: Lorazepam rectally 0.1 mg/kg repeat q5-10 min prn to max of two doses. Give in 1 or 3 mL syringe diluting with NS (1 to 1 dilution), with or without feeding tube, squeezing buttocks together afterwards for 1-2 min. *Tests: CBC, lytes, Ca, Mg, albumin (for pts having phenytoin levels measured), blood cultures, urine cultures (if indicated), urinalysis, antiepileptic drug levels, toxicology screen (blood/urine). Consider: ABGs, LP, CT scan, EEG, metabolic workup and LFTs as per clinical scenario and child < 2 years
Phenobarbital 10 mg/kg IV (max 600 mg).
Max 1 mg/kg/min or 60 mg/min. May give in
staged doses of 10 mg/kg up to max of 40 mg/kg.
and child > 2 years
Phenytoin 20 mg/kg IV (max 1 g): max rate
1 mg/kg/min or 50 mg/min whichever is less;
infuse slowly, monitoring for hypotension and
bradycardia. May give in staged doses of
10 mg/kg up to a max of 30 mg/kg (use 0.22
micron filter and NS only)
Paraldehyde Rectal: 100% (1 g/mL) at 0.2-0.4 mL/kg (200-400 mg/kg/dose,
max 10 mL(10 g)) (may repeat once), dilute in syringe with mineral oil or NS
Paraldehyde IV: 5% solution 2-3 mL/kg (100-150 mg/kg) IV bolus then
0.3-0.4 mL/kg/h (15-20 mg/kg/h) (use glass bottle and vented Nitroglycerin Set PVC tubing) Refractory SE
Consider intubation (if not intubated) and transfer to tertiary care. Consult Critical Care Unit for ongoing seizure management 2. Cheng A, Wil iams BA, Sivarajan BV (editors), The Hospital for Sick Children's Handbook of Paediatrics, 10th edition (2003), The Hospital for Sick Children, Toronto, Canada, Elsevier Canada.

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