New Guideline Issued for Emergency Treatment of Status Epilepticus

October 5th, 2016

CINCINNATI – Status epilepticus, in which patients have continuous or rapid sequential seizure activity for 30 minutes or more, is a major medical emergency with a high potential mortality rate.

Emphasizing the importance of prompt and effective treatment, the American Epilepsy Society (AES) recently released a new guideline to help emergency physicians and other medical professionals treat patients more effectively. The guideline, which focuses specifically on convulsive status epilepticus because it is the most common type of status epilepticus and is associated with substantial mortality, was published in a recent issue of Epilepsy Currents, the AES journal.

Background information in the article notes that between 50,000 and 150,000 Americans have status epilepticus each year, and up to 30% of adults, although less than 3% of children, end up dying.

"This is a valuable new guideline for both children and adults that could change the approach many clinicians take in treating these seizure emergencies," said guideline author Tracy Glauser, MD, of Cincinnati Children's Hospital Medical Center's Comprehensive Epilepsy Center. "The goal of therapy is the rapid termination of the seizure activity to reduce neurological injuries and deaths."

After the stabilization phase, defined as 0-5 minutes of seizure activity and requiring standard initial first aid for seizures as well as initial assessments and monitoring, the guideline calls for a treatment algorithm comprising three phases:

• The Initial therapy phase (5-20 minutes of seizure activity), when it becomes 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.
• The second therapy phase (20-40 minutes of seizure activity) when response to the initial therapy can be assessed. The guideline suggests that reasonable options include fosphenytoin, valproic acid, and levetiracetam, offering no preference among them. Because of adverse events, IV phenobarbital is a reasonable second-therapy alternative if none of the three recommended therapies is available, according to the authors.
• The third therapy phase (40 or more minutes of seizure activity). The guideline recommends that, 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, while continuing EEG monitoring.

Based on the cause of the event or the severity of the seizures, study authors point out, clinicians might go through the phases more quickly or even skip the second phase and move rapidly to the third phase, especially in sick or intensive care unit patients.

"In treating status epilepticus there is an overriding urgency to stop seizures before the 30-minute mark when seizure-associated neurologic injury can occur," guideline coauthor Shlomo Shinnar, MD, PhD, of Albert Einstein College of Medicine and Montefiore Medical Center, said in an AES press release. "This 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."