Status Epilepticus Medication

  • Author: Julie L Roth, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA   more...
 
Updated: May 26, 2011
 

Medication Summary

Most patients with status epilepticus (SE) who are treated aggressively with a benzodiazepine, fosphenytoin, and/or phenobarbital experience complete cessation of their seizures. If SE does not stop, general anesthesia is indicated. The use of pentobarbital, thiopental, midazolam infusion, propofol, levetiracetam, topiramate, valproate, and inhaled anesthetic agents has been described for this purpose.

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Benzodiazepines

Class Summary

These are first-line agents for treating SE. They rapidly achieve therapeutic CNS concentrations after IV administration and act to potentiate action of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the CNS, and rapidly abrogate ongoing seizure activity. Their effect is temporary, which is a limitation; diazepam begins to redistribute out of CNS within minutes. Lorazepam, when available, is thought to be the most effective and has a longer seizure half-life than diazepam. Because the effect is time limited, loading of a traditional AED, such as phenytoin, is recommended soon after administration to help mitigate seizure recurrence.

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Lorazepam (Ativan)

 

Lorazepam is preferred by most neurologists for treatment of SE because of its more prolonged CNS action. It is less fat-soluble than diazepam and therefore takes slightly longer (5-10 min) to stop seizures. It has a smaller volume of distribution than diazepam. Serum concentrations reach 50% of Cmax at 20 min. Lorazepam clears from the brain slower than diazepam but loses protective effect over 30-120 min.

It is important to monitor the patient's blood pressure after administering a dose. Adjust as necessary.

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Diazepam (Diastat, Valium)

 

Diazepam is an extremely lipid-soluble agent that quickly enters the brain in first pass and often stops seizures in 1-2 min. It rapidly distributes to other stores of body fat. Its serum concentration decreases to 20% of maximum concentration (Cmax) 20 min after IV infusion. Individualize dosage and increase cautiously to avoid adverse effects.

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Midazolam (Versed)

 

Midazolam is used as an alternative agent in termination of refractory SE. Because midazolam is water soluble rather than fat soluble, it takes approximately 3 times longer than diazepam to peak EEG effects. Thus, the clinician must wait 2-3 min to fully evaluate sedative effects before repeating a dose.

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Anticonvulsant Agents

Class Summary

These agents are used to terminate clinical and electrical seizure activity and to prevent seizure recurrence. Since the full antiepileptic effect of phenytoin, whether given as fosphenytoin or parenteral phenytoin, is not immediate, use of these agents usually follows administration of an IV benzodiazepine.

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Phenytoin (Dilantin, Phenytek)

 

Phenytoin blocks sodium channels in the CNS. It may act in the motor cortex, where it may inhibit spread of seizure activity. The activity of brainstem centers responsible for tonic phase of grand mal seizures also may be inhibited. The dose should be individualized.

A mainstay in the treatment of SE, phenytoin must be administered slowly and therefore takes longer than benzodiazepines to enter the brain. Phenytoin has the advantage of being a long-term anticonvulsant and can be administered orally after acute illness.

Phenytoin is not water soluble, and must be solubilized in propylene glycol carrier with pH 12 to prepare IV form; therefore, it cannot be given at a rate faster than 50 mg/min without risk of significant hypotension and cardiac arrhythmias, as well as major risk of potential irritation at IV site and vascular compromise of the infused limb. Therefore, its use in SE should be avoided if possible.

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Fosphenytoin (Cerebyx)

 

A phosphorylated phenytoin prodrug, fosphenytoin is highly water-soluble at physiologic pH and therefore is easier to administer than phenytoin. It is hydrolyzed rapidly and completely to phenytoin by endogenous phosphatases after a mean of 8 min and therefore can be administered more rapidly than standard phenytoin. Fosphenytoin also eliminates the risk of phlebitis and purple-glove syndrome seen with phenytoin, while achieving therapeutic CNS levels as quickly as phenytoin.

To avoid the need to perform molecular weight–based adjustments when converting between fosphenytoin and phenytoin sodium doses, the fosphenytoin dose is expressed as phenytoin equivalents (PE).

IM administration of fosphenytoin has been approved. However IV is still the route of choice for SE. Cardiac monitoring is required when this agent is administered IV but is not required for IM administration.

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Barbiturates

Class Summary

This class of anticonvulsant may be useful when SE fails to respond to phenytoin and benzodiazepines. It is the most commonly used third-line drug, but midazolam, propofol, and others are increasingly used in preference to phenobarbital, although no rigorous evidence supports the use of one third-line drug over another.

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Phenobarbital

 

Phenobarbital works at CNS GABA receptors to potentiate CNS inhibition. It exhibits anticonvulsant activity in anesthetic doses. Phenobarbital is the best-studied barbiturate in treatment of SE.

In SE, achieving therapeutic levels as quickly as possible is important. IV dose may require approximately 15 min to attain peak levels in the brain. To terminate generalized convulsive SE, administer up to 15-20 mg/kg. If the patient has received a benzodiazepine, the potential for respiratory suppression significantly increases. Ventilation and intubation may be necessary. Hypotension may require treatment.

Phenobarbital is generally used after phenytoin or fosphenytoin fails. However, it can be used in lieu of phenytoin in certain circumstances.

If the IM route is chosen, administer this agent into a large muscle such as the gluteus maximus or vastus lateralis or other areas where risk of encountering nerve trunk or major artery is low. Permanent neurologic deficit may result from injection into or near peripheral nerves.

Restrict IV use to conditions in which other routes are not possible, either because patient is unconscious or because prompt action is required.

A trend is to recommend agents other than phenobarbital (propofol, midazolam, other barbiturates) for refractory SE.

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Pentobarbital (Nembutal)

 

A short-acting barbiturate with sedative, hypnotic, and anticonvulsant properties, pentobarbital can produce mood alteration at all levels of CNS. Use only in refractory status when other agents have failed. Patients need intubation and respiratory support.

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Anesthetics

Class Summary

These agents stabilize the neuronal membrane so the neuron is less permeable to ions. This prevents the initiation and transmission of nerve impulses, thereby producing the local anesthetic effects. In SE, lidocaine is indicated for refractory cases only and its use is supported only by anecdotal reports. The consensus seems to be moving toward propofol or midazolam infusions for refractory status epilepticus.

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Propofol (Diprivan)

 

A phenolic compound unrelated to other types of anticonvulsants, propofol has general anesthetic properties when administered IV. There are increasing anecdotal reports of its use in refractory status epilepticus. Intubation and ventilation are required. Hypotension may require treatment.

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Contributor Information and Disclosures
Author

Julie L Roth, MD  Neurologist, Epilepsy and General Neurology, Comprehensive Epilepsy Program, Rhode Island Hospital; Assistant Professor, Department of Neurology, The Warren Alpert Medical School of Brown University

Julie L Roth, MD is a member of the following medical societies: American Academy of Neurology and American Epilepsy Society

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew S Blum, MD, PhD  Director, Adult Epilepsy and EEG Laboratory, Comprehensive Epilepsy Program, Rhode Island Hospital; Associate Professor of Neurology, The Warren Alpert Medical School of Brown University

Andrew S Blum, MD, PhD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Jose E Cavazos, MD, PhD, FAAN  Associate Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, Program Director of the Clinical Neurophysiology Fellowship, University of Texas School of Medicine at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center, University Hospital System; Director of the San Antonio Veterans Affairs Epilepsy Center of Excellence and Neurodiagnostic Centers, Audie L Murphy Veterans Affairs Medical Center

Jose E Cavazos, MD, PhD, FAAN is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, and American Neurological Association

Disclosure: GXC Global, Inc. Intellectual property rights Medical Director - company is to develop a seizure detecting device. No conflict with any of the eMedicine articles that I wrote or edited.

Daniel J Dire, MD, FACEP, FAAP, FAAEM  Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center San Antonio

Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

J Stephen Huff, MD  Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Edward H Maa, MD  Chief of Comprehensive Epilepsy Program, Department of Neurology, Denver Health and Hospitals; Assistant Professor, Department of Neurology, University of Colorado School of Medicine and Veterans Affairs Medical Center

Edward H Maa, MD is a member of the following medical societies: American Academy of Neurology and American Epilepsy Society

Disclosure: UCB Pharma Honoraria Speaking and teaching

Mark Spitz, MD  Professor, Department of Neurology, University of Colorado Health Sciences Center

Mark Spitz, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, and American Epilepsy Society

Disclosure: pfizer Honoraria Speaking and teaching; ucb Honoraria Speaking and teaching; lumdbeck Honoraria Consulting

Specialty Editor Board

Erasmo A Passaro, MD, FAAN  Director, Comprehensive Epilepsy Program/Clinical Neurophysiology Lab, Bayfront Medical Center, Florida Center for Neurology

Erasmo A Passaro, MD, FAAN is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Association, and American Society of Neuroimaging

Disclosure: Glaxo Smith Kline Honoraria Speaking and teaching; UCB Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Forest Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Norberto Alvarez, MD  Assistant Professor, Department of Neurology, Harvard Medical School; Consulting Staff, Department of Neurology, Boston Children's Hospital; Medical Director, Wrentham Developmental Center

Norberto Alvarez, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, and Child Neurology Society

Disclosure: Nothing to disclose.

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Chief Editor

Stephen A Berman, MD, PhD, MBA  Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

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Treatment algorithms for convulsive status epilepticus.
Focal status epilepticus. Electroencephalograph (EEG) in a patient with epilepsia partialis continua caused by Rasmussen encephalitis before hemispherectomy. The patient had long-standing, intractable partial epilepsy since the first decade of life. Seizures included complex partial with occasional secondary generalization and repetitive myoclonus involving the left side of the body. Note the frequent epileptiform discharges at 1-2 Hz involving the right frontocentral channels. These were evident on many of the patient's routine EEGs. Clinical myoclonus is often correlated with high-voltage bursts of such activity.
Focal status epilepticus. Electroencephalograph (EEG) in a 35-year-old patient with a history of intractable partial epilepsy, in complex partial status epilepticus. The patient underwent a rapid antiepileptic drug taper as an inpatient for long-term video/EEG monitoring as a presurgical candidate. On clinical observation, the patient abruptly stopped and stared, exhibiting automatisms. This first of 2 EEG fragments covers approximately 30 seconds and illustrates the start and evolution of a seizure in the right temporal lobe. The onset appears to be at Sp2 and T4. Note the time of the event, 18:35 on May 9.
Focal status epilepticus. This electroencephalographic (EEG) fragment was obtained at approximately 12:39 on May 10, 18 hours after the onset of complex partial status epilepticus originating in the right temporal lobe, in a 35-year-old patient with a history of intractable partial epilepsy. Other EEG acquisitions over the interval were identical. On clinical observation, the patient was lethargic, sluggish, and vague, with variable responsivity to examiners. Note the persistent epileptiform discharges at 1.5-2.5 Hz with phase reversal mainly at Sp2 though infrequently shifting to Sp1 and F7. The bulk of the discharges are maximal at Sp2, reflecting their mesial temporal origin, with rare, subtle, and low-amplitude reflection from lateral neocortical channels (F8). Background activities are slow with admixed beta frequencies. This finding corresponds to complex partial status epilepticus.
 
 
 
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