The American Epilepsy Society (AES) has issued a new guideline to help clinicians treat prolonged seizures in adults and children.
Status epilepticus, defined as continuous or rapid sequential seizure for ≥30 minutes, is considered a medical emergency with a high mortality rate for adults (up to 30%) and children (<3%). The guideline, published in Epilepsy Currents, focuses on convulsive status epilepticus in particular because it is the most common form and is associated with significant mortality.
Tracy Glauser, MD, with Cincinnati Children’s Hospital Medical Center’s Comprehensive Epilepsy Center explained, “The goal of therapy is the rapid termination of the seizure activity to reduce neurological injuries and deaths.” Currently, some treatments focus on reducing rather than terminating the seizure through use of inefficient sedatives, paralytics or anticonvulsants.
- Stabilization phase (0–5 minutes of seizure activity), includes standard initial first aid for seizures and initial assessments and monitoring.
- Initial therapy phase (5–20 minutes of seizure activity) when it is clear the seizure requires medical intervention, a benzodiazepine (specifically IM midazolam, IV lorazepam, or IV diazepam) is recommended as the initial therapy of choice, given its demonstrated efficacy, safety, and tolerability.
- Second therapy phase (20–40 minutes of seizure activity) when response (or lack of response) to the initial therapy should be apparent. Reasonable options include fosphenytoin, valproic acid and levetiracetam. There is no clear evidence that any one of these options is better than the others. Because of adverse events, IV phenobarbital is a reasonable second-therapy alternative if none of the three recommended therapies are available.
- Third therapy phase (40+ minutes of seizure activity). There is no clear evidence to guide therapy in this phase. The guideline found strong evidence that initial second therapy is often less effective than initial therapy, and the third therapy is substantially less effective than initial therapy. Thus, if second therapy fails to stop the seizures, treatment considerations should include repeating second-line therapy or anesthetic doses of either thiopental, midazolam, pentobarbital, or propofol (all with continuous EEG monitoring).
Clinicians may proceed through the phases faster or even skip the second therapy phase and move onto the third therapy phase based on the causes or severity of the seizure. Overall, the guideline supports “an aggressive approach to treating status epilepticus and seeks to bring some structure to what can often be a chaotic and dire medical situation.”
For more information visit aesnet.org.