4.8.2 Drugs used in status epilepticus

Step 1 (in community)
ChoiceDrugDosage
1st choiceMidazolam buccal liquid
[off label use in adults]

Dose: As per individualised patient protocol (administered by trained individuals)

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

This is 2nd choice due to lower social acceptability and lower efficacy of this option for most patients.
Step 2 (in hospital)
ChoiceDrugDosage
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

Dose: 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®)Dose:
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

Dose:
As per individualised patient protocol
Step 3 (in hospital)
ChoiceDrugDosage
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

Dose:
See BNF or product literature
Or
Levetiracetam Dose:
See BNF or product literature
Or

Sodium Valproate

Avoid Sodium Valproate if suspect mitochondrial epilepsies – can be fatal

[NB Sodium valproate is contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met – see MHRA

Dose:
See BNF or product literature
Step 4

Admit to ICU/ITU

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

Prescribing Notes

  • 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 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’