Emergent Management of Status Epilepticus.

Status epilepticus is a life-threatening neurologic emergency requiring prompt recognition and treatment. Management follows a patient-specific framework based on semiology, etiology, EEG correlate, and age. Benzodiazepines are first-line treatment, supported by three randomized controlled trials in hospital and prehospital settings, and can be given intravenously, intramuscularly, rectally, or intranasally. If seizures persist, second-line options include phenytoin, fosphenytoin, valproate, or levetiracetam; the Established Status Epilepticus Treatment Trial found all three similarly effective in about half of patients. Refractory cases require IV anesthetics like ketamine or GABA-ergic medications. Evidence increasingly supports ketamine use early in stage 3 status epilepticus and as a second-line option. Prompt antiseizure medication is critical because 'time is brain.'

Study at a glance

Abstract

Status epilepticus is a neurologic emergency that can be life- threatening. The key to effective management is recognition and prompt initiation of treatment. Management of status epilepticus requires a patient-specific-approach framework, consisting of four axes: (1) semiology, (2) etiology, (3) EEG correlate, and (4) age. This article provides a comprehensive overview of status epilepticus, highlighting the current treatment approaches and strategies for management and control. Administering appropriate doses of antiseizure medication in a timely manner is vital for halting seizure activity. Benzodiazepines are the first-line treatment, as demonstrated by three randomized controlled trials in the hospital and prehospital settings. Benzodiazepines can be administered through IV, intramuscular, rectal, or intranasal routes. If seizures persist, second-line treatments such as phenytoin and fosphenytoin, valproate, or levetiracetam are warranted. The recently published Established Status Epilepticus Treatment Trial found that all three of these drugs are similarly effective in achieving seizure cessation in approximately half of patients. For cases of refractory and super-refractory status epilepticus, IV anesthetics, including ketamine and γ-aminobutyric acid-mediated (GABA-ergic) medications, are necessary. There is an increasing body of evidence supporting the use of ketamine, not only in the early phases of stage 3 status epilepticus but also as a second-line treatment option. As with other neurologic emergencies, "time is brain" when treating status epilepticus. Antiseizure medication should be initiated quickly to achieve seizure cessation. There is a need to explore newer generations of antiseizure medications and nonpharmacologic modalities to treat status epilepticus.