Pharmacology
Central Nervous System
Which of the following is first-line for management of status epilepticus:
Answer:
First-line treatment is with intravenous lorazepam if available. Intravenous diazepam is effective but it carries a high risk of thrombophlebitis so should only be used if intravenous lorazepam is not immediately available. Absorption of diazepam from intramuscular injection or from suppositories is too slow for treatment of status epilepticus. When facilities for resuscitation are not immediately available or if unable to secure immediate intravenous access, diazepam can be administered as a rectal solution or midazolam oromucosal solution can be given into the buccal cavity.Management of Status Epilepticus
Pharmacology / Central Nervous System
Last Updated: 21st March 2023
Immediate emergency care and treatment should be given to children, young people and adults who have prolonged (lasting 5 minutes or more) or repeated (3 or more in an hour) convulsive seizures.
Immediate Emergency Care
Immediate measures to manage status epilepticus include positioning the patient to avoid injury, securing the airway, supporting respiration including the provision of oxygen, maintaining blood pressure, obtaining intravenous access, and the correction of any hypoglycaemia. Parenteral thiamine should be considered if alcohol abuse is suspected.
First Line Treatment
If the person with convulsive status epilepticus has an individualised emergency management plan that is immediately available, administer medication as detailed in the plan.
If the person with convulsive status epilepticus does not have an individualised emergency management plan immediately available:
- give a benzodiazepine (buccal midazolam or rectal diazepam) immediately as first-line treatment in the community or
- use intravenous lorazepam if intravenous access and resuscitation facilities are immediately available.
If convulsive status epilepticus does not respond to the first dose of benzodiazepine:
- Continue to follow the person's individualised emergency management plan, if this is immediately available, or give a second dose of benzodiazepine if the seizure does not stop within 5 to 10 minutes of the first dose.
| Drug | Child 1 month - 11 years | Child 12 years - 17 years | Adults |
|---|---|---|---|
| IV lorazepam | 100 micrograms/kg (max. per dose 4 mg) | 4 mg | 4 mg |
| Rectal diazepam | 5 - 10 mg (5 mg in children < 1 years) | 10 - 20 mg | 10 - 20 mg (10 mg in elderly) |
| Buccal midazolam |
|
10 mg | 10 mg |
Second Line Treatment
If there is no response to two doses of a benzodiazepine, second-line treatment options include levetiracetam [unlicensed use], phenytoin, or sodium valproate. Take into account that levetiracetam may be quicker to administer and have fewer adverse effects than the alternative options. If convulsive status epilepticus does not respond to a second-line treatment, an alternative second-line treatment option should be considered under expert advice.
Third Line Treatment
Under expert advice, if second-line treatment options are unsuccessful, phenobarbital or general anaesthesia can be considered as third-line treatment options.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
