Algorithm for acute management of status epilepticus

Status epilepticus is considered present if generalized convulsive seizures or successive seizures without return to baseline last for more than 5 minutes. Rapid hemodynamic stabilization and intravenous access should be initiated followed by immediate administration of first-line treatment. Basic blood tests like glucose should be done to correct for reversible causes. This also includes sub therapeutic level for the antiepileptic drugs the patient is taking. Further evaluation of etiologies like brain imaging or CSF analysis should proceed as the patient receives the successive tiers of management. Refractory status epilepticus occurs if the seizures do not respond to secondary management. Initiation of pharmacologically induced coma should be guided by VEEG to burst or seizure suppression. Hemodynamic support with fluids or pressors may be needed with propofol, benzodiazepines (midazolam), or barbiturates (pentobarbital). Super refractory status epilepticus (SRSE) occurs when seizures persist despite 24 hours of pharmacologically induced coma. Other tertiary treatments for super refractory status epilepticus include therapeutic hypothermia, ketamine, surgery, ketogenic diet, and other treatments. (Contributed by Dr. Robert Beach and Dr. Shahram Izadyar.)