Staged Treatment of Status Epilepticus

Abstract

Status epilepticus (SE), an increasingly recognized neurological issue in the clinical setting, is the second-most frequent life-threatening neurological emergency following stroke. SE has a high mortality rate that is largely contingent on the duration of SE before initial treatment, the etiology of SE, and the patient’s age. SE can be divided into four stages: (1) impending SE, (2) established SE, (3) refractory SE, and (4) super-refractory SE. Different therapeutic strategies are applied in each stage. This review provides up-to-date information on the pharmacotherapy of SE. The treatment of SE is evolving as new medications have become available. Three new preparations—fosphenytoin, rectal diazepam, and parenteral valproate—have implications for the management of SE. However, randomized controlled trials have shown that benzodiazepines should be the initial pharmacological therapy in patients with SE, and despite the paucity of clinical trials comparing medication regimens for acute seizures, there is a broad consensus that immediate diagnosis and treatment are necessary to reduce the morbidity and mortality of this condition. Recent data suggest that midazolam and propofol may substitute for phenobarbital or other long-acting barbiturates to reduce the duration of sedation. Nonconvulsive SE is diagnosed with increasing frequency, as electroencephalographic (EEG) monitoring is performed more often in various clinical situations. In patients with persistent alteration of consciousness with no clear etiology, physicians should obtain an EEG rapidly to identify potential SE. Physicians should rely on a standardized protocol for the management of SE to improve the care for this neurological emergency.