Treatment of convulsive status epilepticus

Status epilepticus (SE) is a medical and neurological emergency requiring prompt and aggressive treatment, particularly for elderly individuals in whom comorbid conditions may increase the severity of consequences in SE. Generalized convulsive status epilepticus (GCSE) is the most common and life-threatening type of SE. It may be overt or subtle in its presentation. Most cases are overt, but as the duration of GCSE increases, its presentation may become more subtle. Progressive electroencephalographic changes also occur during GCSE. A predictable sequence of five electroencephalographic patterns has been identified: (1) discrete seizures with interictal slowing, (2) merging seizures with waxing and waning ictal discharges, (3) continuous ictal sharp or spike-wave discharges, (4) continuous ictal discharges with episodes of generalized flattening, and (5) periodic epileptiform discharges superimposed on a relatively flat background. Several factors affect the prognosis of GCSE, including etiology, age, seizure type, gender, and duration. GCSE may lead to systemic complications and neuronal damage and is often fatal if untreated or inadequately treated. Treatment of GCSE should begin with basic life support measures and monitoring. Ideally, pharmacological treatment should be easy to administer and fast acting. Analysis of data on elderly patients with overt GCSE from a Veterans Affairs cooperative study revealed that success rates of first-line treatment were 71.4% for phenobarbital, 63.0% for lorazepam, 53.3% for diazepam followed by phenytoin, and 41.5% for phenytoin alone. In elderly patients with subtle GCSE, success rates for first-line treatment were 30.8% for phenobarbital, 14.3% for lorazepam, 11.8% for phenytoin, and 5.6% for diazepam followed by phenytoin. Because each drug has advantages and disadvantages, the choice of which agent to use as first-line treatment depends on individual patient characteristics.