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Appendix 2 - Management of Status Epilepticus

Status epilepticus is defined as a continuous seizure lasting for at least 20-30 minutes, or two or more discrete seizures between which the patient does not regain consciousness.

  1. The cause of status is often withdrawal of drugs. A maintenance drug should be initiated early in the course of status and continued at an adequate dosage.
  2. Most morbidity and mortality occurs from inappropriate administration of repeated doses of benzodiazepines in a ward setting. If the patient does not respond to an adequate dose of lorazepam, loading with phenytoin should be initiated.
  3. Lorazepam is preferable to diazepam in the management of status epilepticus. Both drugs are equally rapidly acting and effective in controlling seizures, but lorazepam has a longer duration of anti-seizure action than diazepam (12-24 hours cf. 15-30 minutes).
  4. Remember hypoglycaemia.
  5. Loading doses of phenytoin are often inadequate. The following dose, although outside SPC recommendations, is often more effective: 20mg/kg (1.5g for a 75 kg man) should be given at a rate not exceeding 50mg/min with cardiac monitoring. As much as 30mg/kg may be needed in some patients.
  6. Intravenous phenytoin should still be administered even if the patient has been on oral phenytoin (non-compliance is likely).
  7. Chlormethiazole has significant potential for cardiac and respiratory toxicity, and accumulates in lipid tissue. It has no role to play in the management of status.