First10EM - By Justin Morgenstern - June 3, 2019
..."This post is an update of the original status epilepticus post from 2015. The general algorithm is the same, but a few clarifications were added, and the references were updated.
Although older definitions of status epilepticus focused on seizures lasting more than 30 minutes, a more practical definition is any individual seizure lasting more than 5 minutes or 2 seizures without full recovery of consciousness. From an emergency department standpoint, if a patient is still seizing by the time EMS arrives, it is probably status.
I think the described aggressive approach to status epilepticus makes sense in continuous convulsive seizures. However, in patients whose seizures stop with benzos, but simply recur before the patient returns to their baseline neurologic status, a less aggressive approach is probably warranted. (The key distinction is whether you think there is still generalized seizure activity occurring in the brain, which will result in neuronal death). In intermittent seizures, you probably have time to use a conventional anticonvulsant as the second line therapy.
I don’t recommend fosphenytoin. Although it can be given quicker, it doesn’t work any faster or better than phenytoin. Some studies have demonstrated lower side effects with fosphenytoin, but if you look closely, the only side effect that seems to be decreased is pain at the injection site. (Glauser 2016) That doesn’t make sense for patients in status, as they will be unconscious.
I use the same algorithm in both children and adults, as the underlying pathophysiology is the same, and there is little reason to think that the treatment needs to differ. (Glauser 2016) That being said, outcomes tend to be better in children, so a less aggressive approach may be warranted in some circumstances.
Obviously, this aggressive algorithm is not appropriate for non-epileptic spells, or pseudoseizures. Pseudoseizures are usually relatively obvious clinically. Indicators of a non-epileptic spell include maintained consciousness, poorly coordinated thrashing, purposeful movements, back arching, eyes held shut, head rolling, and pelvic thrusting. (Claassen 2017)"
