Status epilepticus is one of the true neurologic emergencies, where minutes may actually count. Prompt and definitive treatment often yields excellent outcomes, whereas sluggish or inappropriate treatment can have severe consequences. Management has changed substantially over the past decade including a new definition of convulsive status epilepticus (>5 minutes of seizing, rather than >30 minutes) and the emergence of newer and safer anti-epileptics (e.g. evetiracetam, lacosamide, and ketamine). Like all of critical care this remains an area of considerable controversy, but new evidence is helping to provide some clarity (e.g. the ESETT trial).
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Thanks for this comprehensive summary!
Often with status epilepticus I’m wondering about the timing of intubation. Some patients arrive at our emergency department when they’ve already been seizing for about 30 minutes, the benzos in the ambulance didn’t have any effect. Provided you have no immediate indication for intubation (compromised airway for example), how long you would try to stop the seizure with anti-epileptic agents before moving on the intubation? I’d think that the ‘Time is brain’ rhetoric from stroke care also applies here.
This is minor in the grand scheme of things, but I am assuming that you meant to say that fosphenytoin is dosed in “phenytoin equivalents” rather than “phosphenytoin equivalents.” Additionally, it’s “mg PE,” not just PE, cumbersome-sounding as that terminology may be…
Love the article and your work on the IBCC overall!
Hello, very good post and too much knowledgeable and I am looking forward to reading more of like this post.
Great Work would Love to read more.
As always, very informative post! Thank you.. I can’t help but think; you guys really need an ED Pharmacist at your site! I’ve heard a lot of comments on these posts about things “taking 20-30 minutes to come from Pharmacy,” “if only Pharmacy could get this up here faster,” etc. In our ED, we have vials of levetiracetam in the medication rooms (Pyxis machines, to be exact), and the PharmD can draw doses of levetiracetam needed for these patients in a matter of minutes. This is the same for most vasopressors (norepinephrine is pre-made and stocked in Pyxis, and we… Read more »
Great article as always ! Properly dosing benzos seems paramount to break seizures. I was hoping you could clarify whether you are using: Weight based doses for two doses of lorazepam (ie 80kg man – 8mg lorazepam, followed by another 8mg for next dose), or dividing the weight based dose over 2 doses (ie 4mg then another 4mg)? Even looking through the pediatric data, the RAMPART study pediatric subgroup used 2mg lorazepam if 13-40kg, then 4mg if >40kg, although no mention of repeat or rescue dosing. The PECARN study PMID 24756515 compared lorazepam to diazepam at 0.1 mg/kg v 0.2… Read more »
In the text it was mentioned that Propofol blocks the GABA receptor. However, It is a GABAa receptor agonist. It does not block it.