4.8.2 Drugs used in status epilepticus

Step 1 (in community)
ChoiceDrugDosage
1st choiceMidazolam buccal liquid

Dose:
As per individualised patient protocol

NB prescribe by brand name to reduce risk of confusion between different preparations.

2nd choiceDiazepam rectal solution 10mg/2.5mlDose: Usually 10mg, or as per individualised patient protocol
Step 2 (in hospital)
ChoiceDrugDosage
1st choicesLorazepam injection 4mg/mlDose:
By intravenous injection (into large vein), 4mg repeated once after 10 minutes if necessary
Or
Diazepam injection (emulsion) 5mg/ml (Diazemuls®)Dose: By slow intravenous injection, 10mg at a rate of 1ml (5mg) per minute, repeated once after 10 minutes if necessary
Or

Midazolam buccal liquid

N.B. to be used only when IV access not available

Dose:
As per individualised patient protocol
Step 3 (in hospital)
ChoiceDrugDosage
1st choicesFosphenytoin sodium

N.B. prescriptions for fosphenytoin sodium should state the dose in terms of phenytoin sodium equivalent (PE), fosphenytoin sodium 1.5mg Ξ phenytoin sodium 1mg
Dose:
See BNF or product literature
Or
Phenytoin sodium injection 50mg/ml Dose:
See BNF or product literature
2nd choicePhenobarbital (phenobarbitone) injection 200mg/ml  Dose:
See BNF or product literature
Step 4

Admit to ICU/ITU

Prescribing Notes

  • Status epilepticus is defined, from the perspective of when to start treatment, as seizures which last for more than 5 minutes or a series of seizures which takes place without the patient regaining consciousness in between them.

Community

  • The first episode of status epilepticus should be treated with buccal midazolam if available, and an ambulance should be called.
  • Treatment should be given if convulsion lasts longer than 5 minutes. Buccal midazolam should be given by a trained healthcare professional or carer, according to the individual agreed protocol drawn up for the patient by the specialist.
  • Clinicians should refer to HSCB Medicines Safety Alert.
  • Information regarding training for the administration of buccal midazolam can be obtained by contacting the HSC Trust epilepsy specialist nurses.

Hospital

  • If still fitting at 10 minutes and, if not already in hospital, call an ambulance. A second dose may be given sooner if resuscitation facilities are available.
  • If convulsion continues beyond 30 minutes (status epilepticus), patient will need hospitalisation and preferably admission to ICU/ITU.
  • Although the BNF recommends lorazepam injection, this requires refrigeration.
  • Clobazam may be prescribed to prevent status epilepticus in patients with a previous history of status or who are known to be at risk if their seizures accelerate or begin to cluster. It may also be prescribed for those whose seizures occur or accelerate at certain times e.g. during menstruation or intercurrent infections. Prescriptions should be endorsed ‘SLS’.
  • Fosphenytoin sodium, although difficult to administer, has distinct advantages over phenytoin with respect to speed of administration and pH.