Status Epilepticus

Question 1

Diazepam

Answer 1

5 - 10 mg IV
Rectal: 0.2 - 0.5 mg/kg (max: 20 mg)
Highly lipophilic - rapid redistributes out of the CNS

Question 2

Fosphenytoin

Answer 2

20 mg PE/kg IV
Water-soluble prodrug of phenytoin
Rate: 150 mg PE/min - low risk of extravasation and CV ADRs
Plasma concentrations should not be measured until about 2 hours after IV dose
1 mg PE = 1 mg phenytoin sodium

Question 3

Lacosamide

Answer 3

200 - 400 mg IV
Mixed evidence
May be useful in patients with cardiorespiratory compromise

Question 4

Levetiracetam

Answer 4

40 - 60 mg/kg IV (max: 4500 mg)
Useful in patients with cardiorespiratory compromise
No DDI

Question 5

Lorazepam

Answer 5

4 mg IV
Less lipophilic than diazepam
IM but IV preferred

Question 6

Midazolam

Answer 6

10 mg IV/IM
Water soluble
Intranasal (5-10 mg)
Buccal (10 mg) - more efficacious than rectal diazepam in children
Short half-life
Tachyphylaxis
Lower in renal when used as infusion
Titrate to “burst suppression” on EEG

Question 7

Pentobarbital

Answer 7

5 - 10 mg/kg IV
Accumulates in adipose tissue (prolonged half-life)
More effective than propofol and midazolam, but higher rates of hypotension
Increase risk of ileus and infxn
“Burst suppression” on EEG
Requires intubation and vasopressor therapy
Monitor for propylene glycol toxicity
Infusion not to exceed 50 mg/min

Question 8

Phenytoin

Answer 8

20 mg/kg IV
Infusion rate not to exceed 50 mg/min
Soluble in propylene glycol and compatible ONLY in NS
Hypotension core common in elderly
Do not use IM route for status epilepticus

Question 9

Phenobarbital

Answer 9

15-20 mg/kg IV
Long half-life
Infusion rate of 50-100 mg/min
May not be effective if status epilepticus persists despite BZD and phenytoin therapy

Question 10

Propofol

Answer 10

1-2 mg/kg IV
Short half-life
“Burst suppression”
Requires intubation and vasopressor therapy
Provides calories (1 kcal/mL)
Caution warranted when using at > 5 mg/kg/hr for > 48 hours
CI: pts with h/o soy or egg allergy

Question 11

Propofol-Related Infusion Syndrome

Answer 11

When used for > 48 hours
Rhabdomyolysis
Hyperkalemia
Metabolic acidosis
Cardiac arrhythmias

Question 12

Valproic Acid

Answer 12

20-40 mg/kg IV (max: 3000 mg)
Particularly useful in patients with cardiorespiratory compromise
May also be useful for absence status epilepticus