Published in:
01-09-2014 | What's New in Intensive Care
What’s new in status epilepticus?
Published in: Intensive Care Medicine | Issue 9/2014
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Status epilepticus (SE) is essentially an acute, prolonged epileptic crisis, defined by a continuous seizure that lasts 5 min or more. It is the second-most frequent life-threatening neurological emergency after stroke and bears considerable risks of morbidity and mortality [1, 2]. To prevent potentially dismal complications, recent North American and European guidelines strongly advocate timely (immediate to urgent) treatment. At present, the therapeutic arsenal is subdivided into three lines, consisting of the administration of benzodiazepines (first line of treatment), of antiseizure drugs (second line of treatment), and of general anesthetics (third line of treatment) [3, 4]. Despite this relatively simple approach, several uncertainties are associated with the optimal use of specific agents and the best sequence of their administration [2, 5]. Our recommended strategy for treating SE treatment is given in Fig. 1. In subsequent sections of this article we provide an overview of the most recent clinical findings corroborating this strategy.
Fig. 1
Flow chart of status epilepticus (SE) treatment, with standard dosages and administration routes. The middle line (MDZ, VPA) is preferred; alternatives are indicated on the left and right side. The first line of treatment (benzodiazepines) is shown in green boxes; the second line of treatment [intravenous (IV) antiepileptic compounds] in blue boxes, and the third line of treatment (IV general anesthetics) in orange and lilac boxes; additional lines are given in red boxes. In patients with ongoing SE without severe consciousness impairment, non-sedating antiepileptic agents should be preferred—at least initially—to anesthetic agents (orange box). PO oral administration, IM intramuscular injection. Single asterisk Not suitable for some generalized syndromes (including myoclonic or absence seizures), double asterisks use in combination with benzodiazepines, but avoid prolonged use without checking creatine kinase, lactate, and triglycerides. CLZ clonazepam, ECT electro-convulsive treatment, LCM lacosamide, LEV levetiracetam, LZP lorazepam, MDZ midazolam, PGB pregabalin, (P)PHT (phospho-)phenytoin, PRO propofol, PTB pentobarbital, THP thiopental, rTMS repetitive transcranial magnetic stimulation, TPM topiramate, VNS vagus nerve stimulation, VPA valproate
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