Status Epilepticus Management: We’ve Been Doing it Right All Along
ABSTRACT & COMMENTARY
Source: Treiman DM, et al. Comparison of four treatments for generalized convulsive status epilepticus. New Engl J Med 1998;339:792-798.
Treiman and colleagues compared four accepted therapies for generalized convulsive status epilepticus (GCSE) in a five-year, double-blind, multicenter study. Patients were randomized to receive either lorazepam (0.10 mg/kg), phenytoin (18 mg/kg), phenobarbital (15 mg/kg), or diazepam (0.15 mg/kg) plus phenytoin (18 mg/kg). Therapeutic success was defined as resolution of the seizure both by exam and EEG within 20 minutes and no recurrence within 40 minutes. Patients were classified as presenting with either clinically overt seizures or subtle seizures (coma with EEG evidence of seizure ± convulsions).
In the 384 enrolled patients presenting with overt GCSE, lorazepam successfully aborted the seizure in 65% while phenytoin alone aborted the seizure in 44% (P = 0.002). There were no significant differences in success among the other therapies and in other comparisons. Among the 134 patients with subtle GCSE, overall success was only 15%, and no therapy appeared superior. Combining overt and subtle GCSE patients, lorazepam was more effective than phenytoin (52% vs 37%; P = 0.001), and, again, there were no significant differences in other comparisons. Treiman et al recommend lorazepam as the drug of choice for initial management of GCSE.
Commentary by David J. Karras, MD, FACEP
Initial management of GCSE with a benzodiazepine (BZD) is a no-brainer for most emergency physicians. Many neurologists have not embraced BZDs as the therapy of choice, however, and I’ve had heated debates with my neurologist colleagues about my decision to use lorazepam rather than phenytoin as initial therapy for GCSE. The neurologists’ argument favoring phenytoin is that it is a definitive anticonvulsive agent; their argument against lorazepam is that it causes prolonged sedation, is not definitive therapy, and makes later EEG testing unreliable. Nevertheless, I prefer lorazepam as initial therapy because of its efficacy, rapidity of onset, excellent safety profile, prolonged duration of action, and incomparable ease of administration. Most emergency physicians choose to abort the seizure as quickly as possible with a BZD and address long-term control with a definitive agent after the convulsive activity has ceased.
It is nice to see my management approach vindicated by this study. However, the low success rate of each of the therapies in aborting GCSE is concerning. Treiman et al attribute this to their stringent definitions of both status epilepticus and treatment success. Of note, 65% of patients with subtle GCSE died within 30 days, perhaps reflecting the difficulty in making this diagnosis and the gravity of the associated underlying conditions.