Almost all published protocols and guidelines refer to generalized convulsive SE (GCSE). Generalized nonconvulsive SE (NCSE) after convulsions should probably be considered as much of an emergency as GCSE. Other forms of SE are of less certain morbidity and urgency. Medication use is generally similar, if less immediate. Nevertheless, the pathophysiologic underpinnings of many different types of SE (with the possible exception of absence SE, EPC, and myoclonic status after anoxia) argue for urgent treatment in almost all cases. Other forms of SE can lead to convulsions, and a casual approach is inappropriate.

Rather than choose one protocol for all patients, keep in mind the principles in the Guidelines. Table: Guidelines for SE Treatment

Emergency medical management

The goal of medical management is to normalize blood pressure, volume status, temperature, ventilation, and oxygenation. As in other emergencies, attention to airway, breathing, and circulation (the ABCs) is crucial. Patients with GCSE or coma from other forms of SE usually need intubation, at least for airway protection. Use of a soft oral airway tube is reasonable, but forced insertion or the use of hard objects is not. Physical safety and prevention of further injury must be assured.

Intravenous access must be established. Thiamine and a bolus of 50% glucose should be infused after a reliable normal saline intravenous line is started.

ECG monitoring should continue to watch for arrhythmias and ischemia.

Hypomagnesemia may worsen seizures, and magnesium is appropriate for alcoholic or malnourished patients.

Drug overdoses may prompt gastric emptying or even hemodialysis.

Treating SE with medications

Several medications are widely used for the treatment of SE. Studies comparing some of these in GCSE have recently appeared but no medication is generally accepted as best in all circumstances. Table: Drug Treatment

Rather than trying to decide on "the best anticonvulsant," it may be more useful to consider medications in two groups:

• Very rapidly acting anticonvulsants, which are often necessary for the interruption of SE, especially when the physiologic and pathologic consequences of GCSE are imminent. This group is largely limited to benzodiazepines, which are invaluable in interrupting continuous seizures but may not be necessary when seizures are discrete, even with incomplete recovery.



• Anticonvulsants that work less rapidly but provide continued protection against the reemergence of SE. This type is almost always necessary after the first few minutes. The goal must be to stop continuous convulsions or other seizures and to interrupt continuing EEG discharges. Phenytoin, valproic acid, and phenobarbital are the most widely used drugs in this group because they have intravenous formulations that can be quickly administered, but most other anticonvulsants have been used.

Adapted from: Drislane FW. Status epilepticus. In: Schachter SC, Schomer DL, eds. The comprehensive evaluation and treatment of epilepsy. San Diego, CA: Academic Press; 1997. p. 149-172.
With permission from Elsevier (www.elsevier.com)
Reviewed and revised February 2004 by Thaddeus Walczak, MD, MINCEP® Epilepsy Care, Minneapolis, MN