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Evaluation and Management of Status Epilepticus

Recommendations

SE Definition and Classification

SE should be defined as 5 min or more of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures. (Moderate, Strong)
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SE should be classified as either convulsive SE (convulsions that are associated with rhythmic jerking of the extremities) or non-convulsive SE (seizure activity seen on EEG without the clinical findings associated with convulsive SE). (High, Strong)
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Refractory SE should be defined as SE that does not respond to the standard treatment regimens, such as an initial benzodiazepine followed by another AED. (Moderate, Strong)
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The etiology of SE should be diagnosed and treated as soon as possible. (High, Strong)
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Treatment

The treatment of convulsive SE should occur rapidly and continue sequentially until clinical seizures are halted. (High, Strong)
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The treatment of SE should occur rapidly and continue sequentially until electrographic seizures are halted. (Moderate, Strong)
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Critical care treatment and monitoring should be started simultaneously with emergent initial therapy and continued until further therapy is consider successful or futile. (Moderate, Strong)
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Treatment options

Benzodiazepines should be given as emergent initial therapy. (High, Strong)
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Lorazepam is the drug of choice for IV administration. (Moderate, Strong)
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Midazolam is the drug of choice for IM administration. (Moderate, Strong)
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Rectal diazepam can be given when there is no IV access and IM administration of midazolam is contraindicated. (Moderate, Strong)
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Urgent control AED therapy recommendations include use of IV fosphenytoin/phenytoin, valproate sodium, or levetiracetam. (Moderate, Strong)
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Refractory SE therapy recommendations should consist of continuous infusion AEDs, but vary by the patient’s underlying condition. (Low, Strong)
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Dosing of continuous infusion AEDs for RSE should be titrated to cessation of electrographic seizures or burst suppression. (Very Low, Strong)
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A period of 24–48 h of electrographic control is recommended prior to slow withdrawal of continuous infusion AEDs for RSE. (Very Low, Weak)
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During the transition from continuous infusion AEDs in RSE, it is suggested to use maintenance AEDs and monitor for recurrent seizures by cEEG during the titration period. If the patient is being treated for RSE at a facility without cEEG capabilities, consider transfer to a facility that can offer cEEG monitoring. (Very Low, Strong)
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Alternative therapies can be considered if cessation of seizures cannot be achieved; however, it is recommended to reserve these therapies for patients who do not respond to RSE AED treatment and consider transfer of the patient if they are not being managed by an ICU team that specialize in the treatment of SE and/or cannot provide cEEG monitoring. (Very Low, Weak)
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cEEG

The use of cEEG is usually required for the treatment of SE. (Very Low, Strong)
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Continuous EEG monitoring should be initiated within 1 h of SE onset if ongoing seizures are suspected. (Low, Strong)
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The duration of cEEG monitoring should be at least 48 h in comatose patients to evaluate for non-convulsive seizures. (Low, Strong)
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The person reading EEG in the ICU setting should have specialized training in cEEG interpretation, including the ability to analyze raw EEG as well as quantitative EEG tracings. (Low, Strong)
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Recommendation Grading

Overview

Title

Evaluation and Management of Status Epilepticus

Authoring Organization

Publication Month/Year

April 24, 2012

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Emergency care

Scope

Assessment and screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D013226 - Status Epilepticus

Keywords

status epilecticus