[Generalized tonic-clonic status epilepticus: therapeutic strategy]

BASIC STRATEGY: Generalized tonic-clonic status epilepticus is a medical emergency requiring very rapid administration of anti-epilepsy drugs to avoid or prevent neurological damage. First intention treatment is based on rapid-action intravenous benzodiazepine (BZD) associated with another long-action anti-epilepsy drug. General anesthesia with respiratory assistance may be needed if the seizures are refractory. We considered the pharmacodynamic, pharmacokinetic and pharmacoeconomic properties of drugs proposed for the treatment of status epilepticus.

An analysis of the literature and clinical practice show that, used alone, BZDs have a rapid effect and are effective in 54 to 84% of the cases. When hydantoins are combined with BZD, cessation of seizures can be achieved in 94% of the patients compared with 82% when phenobarbital is used alone. However, the administration of hydantoins requires 15 to 30 min whereas phenobarbital is effective in 5 minutes. Irrespective of the type of BZD combined with hydantoins, no difference has been observed concerning clinical efficacy. Midazolam appears to be as effective as barbiturics. Cardiac function must be monitored when hydantoins are used although admission in an intensive care unit may not be required, unlike the situation with phenobarbital that may lead to intubation.

Considering non-refractory status epilepticus, a comparison of the efficacy of the proposed drugs, their side effects and their cost demonstrates a good cost/benefit ratio for phenobarbital and good tolerance for fosphenytoin. If cessation of the seizures cannot be achieved, other therapeutic strategies may have be to used: induction of barbituric coma with thiopental, general anesthesia using propofol, or midazolam or lidocaine.