QuestionSBA
QuestionChoice
This would be the last resort treatment option in refractory status epilepticus where the seizure activity is unable to be controlled with other agents
33467
e
Rapid sequence induction of anaesthesia
QuestionChoice
Intravenous sodium valproate is an anticonvulsant drug; however, it is less appropriate agent in this context. The patient is known to be on levetiracetam normally to good effect, is any anticonvulsant were to be given, it should be the patient's usual medication. Additionally, valproate should be avoided where possible in women of child-bearing age
33466
d
Intravenous sodium valproate
QuestionChoice
The patient is usually on levetiracetam, and this may be given intravenously if the seizure cannot be terminated with benzodiazepines alone; however, it is not a first-line agent for the management of status epilepticus
33465
c
Intravenous levetiracetam
QuestionChoice
This may be used in the community, and family members can be trained to administer this if loved ones are prone to having seizures. Where the patient is in hospital and has intravenous access, lorazepam would be more appropriate
33464
b
Rectal diazepam
QuestionChoice
Benzodiazepines are the first-line agents for terminating seizures. They can be given in the form of intravenous lorazepam, buccal midazolam or rectal diazepam, depending on the context, access and availability of medication. Where possible, intravenous lorazepam should be the first choice. A second dose can be given if the seizure does not terminate within 10 minutes of the first dose
33463
a
Intravenous lorazepam
QuestionComment
Surely it isn't status since it has been more than 5 mins since the termination of her first seizure?
9927
QuestionComment
not sure but maybe being post ictal implies that she had incomplete resolution from the first seizure in which case it would be status ? 
22949
User
subscriber
yuvi
User
subscriber
Abrasion DNA
QuestionComment
i think recent guidelines have changed so that you administer a second dose of BZD if the seizure does not terminate within 5 minutes of the first dose
22991
QuestionComment
I think it's IV Lorazzy if you already have access.
28576
User
subscriber
Axillary Transplant
User
subscriber
Will
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)
196
196
Status Epilepticus
Topic
34
Neurology
Video
Concept
196
Status Epilepticus
129
9WkzgUc
images/videos/neurology.png
Epilepsy syndromes
6693
A 27-year-old female with a history of epilepsy is brought into the Emergency Department by ambulance following a seizure at home 20 minutes ago. She usually takes levetiracetam. She is post-ictal and has intravenous access established by the ambulance crew. During your assessment, she starts having a second seizure.

What is the first-line agent to stop this patients seizure?
a