Contributor: Alec Coston, MD
Educational Pearls:
Most generalized seizures terminate spontaneously, with up to 90% stopping within 4 minutes.
The American Epilepsy Society defines 0–5 minutes as the stabilization phase of a seizure.
If a seizure continues for 5 minutes, begin treatment for status epilepticus with a benzodiazepine.
If the patient becomes hypoxic or otherwise unstable, intervene immediately.
Waiting can help avoid unnecessary benzodiazepine administration and the resulting sedation, which can be difficult to distinguish from a postictal state.
When benzodiazepines are indicated, adequate initial dosing is important:
Lorazepam (Ativan): 0.1 mg/kg IV, maximum 4 mg
Midazolam (Versed): 10 mg IM for adults >40 kg when IV access is unavailable
Midazolam dosing differs by route. Although weight-based doses such as 0.2 mg/kg are used in some settings, the American Epilepsy Society guideline specifically recommends 10 mg IM for patients >40 kg, based largely on the RAMPART trial.
Benzodiazepines are commonly underdosed in status epilepticus, which may decrease the likelihood of terminating the seizure and delay administration of second-line antiseizure medications.
References:
Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48.
Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus. N Engl J Med. 2012;366(7):591-600. doi:10.1056/NEJMoa1107494.
Sathe AG, Underwood E, Coles LD, et al. Patterns of Benzodiazepine Underdosing in the Established Status Epilepticus Treatment Trial. Epilepsia. 2021;62(3):795-806. doi:10.1111/epi.16825.
Summarized by Sam Pahl | Edited by Sam Pahl & Ahmed Abdel-Hafiz, NREMT-P
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