QuestionSBA
QuestionChoice
IV phenytoin is given third-line for status epilepticus after the patient has received two doses of benzodiazepine (e.g. IV lorazepam), 10 minutes apart
33717
e
Give IV Phenytoin 15mg/kg
QuestionChoice
PR diazepam (or buccal midazolam) is given first-line in status epilepticus in the community as these patients usually don't have IV access. As this patient is in hospital and has IV access, lorazepam is more appropriate
33715
c
Give PR diazepam 10 mg
QuestionChoice
Rapid sequence induction is considered after seizure activity for 45 minutes, reserved for patients who cannot have their seizures terminated with benzodiazepines or other drugs like phenytoin
33716
d
Rapid sequence induction with sodium thiopentone
QuestionChoice
50 ml of IV glucose 50% is given to patients in status epilepticus who have hypoglycaemia. This patient has a normal glucose, however, so this therapy is not appropriate
33714
b
Give 50 ml of IV glucose 50%
QuestionChoice
This patient is in status epilepticus, as they have had a seizure lasting more than 5 minutes. As they are in status epilepticus, they should be treated with a seizure terminating medication. The first-line medication in status epilepticus in a hospital setting is IV lorazepam if the patient has IV access
33713
a
Give IV lorazepam 4mg
Concept
Chapter
# Summary

Status Epilepticus is defined as a seizure lasting 5 minutes or more, or multiple seizures occurring within a 5-minute window without regaining full consciousness between episodes. It is a medical emergency, and treatment should begin promptly at the 5-minute mark. Initial management involves administering benzodiazepines, such as rectal diazepam, buccal midazolam, or intravenous lorazepam. If there is no response to two doses of benzodiazepines, second-line treatments include levetiracetam, phenytoin, or sodium valproate. Refractory cases may require general anesthesia with agents like propofol or midazolam. Investigations include blood tests, toxicology screen as well as neuroimaging and CSF analysis if the cause remains unclear

# Definition

Status epilepticus is defined as a seizure lasting 5 minutes or more OR multiple seizures over 5 minutes without returning to a full level of consciosuness between episodes.

It should be assumed at 5 minutes and appropriate treatment and investigations initiated.

# Acute management of status epilepticus

Emergency AED therapy for convulsive status epilepticus [NICE guidelines](https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures):




**Premonitory stage (0-10 minutes)** 

- Diazepam 10−20 mg given rectally, repeated once 15 minutes later if status continues to threaten, or midazolam 10 mg given buccally. If seizures continue, treat as below.

**Early status (0-30 minutes)** 

- If in the community:
	- Buccal Midazolam or Rectal Diazepam 
- If IV access is obtained and resuscitation facilities are available:
	- Lorazepam (intravenous) 0.1 mg/kg (usually a 4 mg bolus, repeated once after 10−20 minutes; rate not critical). 

**Established status (0-60 minutes)** 

- If not responding to 2 doses of benzodiazepine, give any of the following as second-line treatment
	- Levitiracetam
	- Phenytoin
	- Sodium Valproate

**Refractory status (30-90 minutes)**

- General anaesthesia, with one of:

	- Propofol (1–2 mg/kg bolus, then 2–10 mg/kg/hour) titrated to effect
	- Midazolam (0.1–0.2 mg/kg bolus, then 0.05–0.5 mg/kg/hour) titrated to effect
	- Thiopental sodium (3–5 mg/kg bolus, then 3–5 mg/kg/hour) titrated to effect; after 2–3 days infusion rate needs reduction as fat stores are saturated
	- Anaesthetic continued for 12−24 hours after the last clinical or electrographic seizure, then dose tapered.


# Investigations

- Arterial Blood Gas
- Routine Blood tests including FBC, U&E, LFT, CRP, Clotting, Bone Profile 
- Toxicology screen (urine)
- Anti-epileptic drug levels (if appropriate)
- If the underlying cause is unclear, further investigations can include:
	- CT/MRI Brain Imaging
	- Lumbar Puncture 


# References

[Click here for the NICE guidelines on managing status epilepticus](https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures)
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Status Epilepticus
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Neurology
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Concept
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Status Epilepticus
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Epilepsy syndromes
6743
A 64-year-old man is brought to the emergency department with a stroke. Bloods are taken, and IV access is obtained. While in the emergency department, he begins to have a seizure. His oxygen saturations are 97%, and his blood glucose is 5.6 mmol/L (normal <6.1 mmol/L). Five minutes have now passed.


Which of the following is the best next step in the management of this patient?
a