Management of status epilepticus

1. Protect airway.

2. Give oxygen 10 L/min via high-flow
mask.

3. Administer benzodiazepine iv or rectally.
Lorazepam is preferred because of long duration of anti-epileptic
effect. This is effective in ~80% cases.

4. If the patient does not respond, the regime may
be repeated after 5-10 minutes using the same or a different
benzodiazepine.

5. If seizures recur or fail to respond after 30 minutes a parenteral
anti-epileptic agent should be started.

• Intravenous phenytoin is usually used and is given as a loading dose of
  18mg/kg. Adverse effects are common and include CNS depression and cardiac
  arrhythmias.

• Fosphenytoin, a disodium phosphate
  ester of phenytoin, has several advantages over phenytoin: it can be given iv
  or im (phenytoin can only be given iv) and can be given at infusion rates
  three times faster than phenytoin; therapeutic levels are achieved within 10
  minutes; and it has a lower incidence of adverse events than phenytoin.
  Fosphenytoin is a pro-drug of phenytoin - metabolized in the body to phenytoin
  and endogenous phosphates.

• If the patient is already taking phenytoin, either iv phenytoin or
  fosphenytoin should still be given: it is likely that plasma levels are
  subtherapeutic.

6. The anaesthetic agents thiopental and propofol
may be effective in controlling SE if the above measures fail (unlicensed
indication) but should only be done with full intensive care support.