4.8.2 Drugs used in status epilepticus


Choice	Drug	Dosage
1st choice	Midazolam buccal liquid [off label use in adults]	As per individualised patient protocol (administered by trained individuals) NB prescribe by brand name to reduce risk of confusion between different preparations.
2nd choice	Diazepam rectal solution 10mg/2.5ml	Usually 10mg, or as per individualised patient protocol This is 2nd choice due to lower social acceptability and lower efficacy of this option for most patients.


Choice	Drug	Dosage
1st choice (reduced doses of benzodiazepines should be administered in hospital if they have already been administered to the patient prior to admission. This is at clinician discretion)	Lorazepam injection 4mg/ml	By intravenous injection (into large vein), 4mg given once, and after 5-10minutes a further dose of lorazepam can be administered if necessary. NB. the combined first and second dose of lorazepam should not exceed 0.1mg/kg total.
		Or
		Diazepam injection (emulsion) 5mg/ml (Diazemuls®)	By slow intravenous injection, 10mg at a rate of 1ml (5mg) per minute, repeated once after 10 minutes if necessary (Max dose 20mg in total)
		Or
		Midazolam buccal liquid N.B. to be used only when IV access not available	As per individualised patient protocol


Choice	Drug	Dosage
1st choice The first choice for the next drug agent used in convulsive status epilepticus should be guided by the local trust	Phenytoin sodium injection 50mg/ml	See BNF or product literature
		Or
		Levetiracetam	See BNF or product literature
		Or
	Sodium Valproate Avoid Sodium Valproate if suspect mitochondrial epilepsies – can be fatal (Valproate must not be started in new patients (male or female) < 55 years, unless two specialists independently consider and document that there is no other effective or tolerated treatment, or there are compelling reasons that the reproductive risks do not apply. Any use of valproate in women of childbearing potential who cannot be treated with other medicines must be in accordance with the Pregnancy Prevention Programme. See MHRA.)	See BNF or product literature

Admit to ICU/ITU

Pharmacological management is with anaesthetic agents and ideally will be guided with ICU and neurology input.

Convulsive status epilepticus is a medical emergency, which can be life-threatening.
It is operationally defined based on timeframes of when to start treatment. It is a seizure episode which lasts for more than 5 minutes or a series of shorter seizures which take place without the patient regaining consciousness between seizures lasting 5 minutes

Community

The initial episode of convulsive status epilepticus should be treated with buccal midazolam if available and an ambulance should be called.
Give immediate emergency care and treatment if prolonged (lasting 5 minutes or more). Some care plans may have a provision in acute repetitive seizures for midazolam administration.
Treatment should be administered by trained clinical personnel or, if specified by an individually agreed protocol drawn up with the specialist, by family members or carers with appropriate training.

Hospital

A second dose of benzodiazepine drug may be given if resuscitation facilities are available. Do not exceed specified maximum doses.
For non-benzodiazepine IV drug infusions used as second line treatment (e.g. phenytoin, levetiracetam) the choice between these agents is based on expert opinion. Phenytoin is used most commonly. The essential aspect is to give the correct mg/kg dose in a timely manner.
If status epilepticus continues beyond 30 minutes (refractory status epilepticus), the patient will need urgent assessment for admission to ICU.
Note that lorazepam injections should be refrigerated to ensure product stability.
Clobazam may be prescribed to prevent status epilepticus in patients with a previous history of status epilepticus or in those who are known to be at risk of a seizure cluster. It may also be prescribed for those whose seizures occur relatively predictably at certain times e.g. during menstruation or intercurrent infections. Prescriptions should be endorsed ‘SLS’.