Treatment of status epilepticus

Status epilepticus (SE) is a neurological emergency that requires prompt diagnosis and treatment, as delay is associated with a higher likelihood of poor response to treatment and worse outcome. Lorazepam has been well established as a first-line therapy. Subsequent steps are less established, and there are many reasonable options, including intravenous fosphenytoin, valproate, midazolam, propofol, and phenobarbital. If intravenous access is not immediately available, rectal diazepam or nasal or buccal midazolam should be given; this can also be used as out-of-hospital treatment to prevent or treat SE. For refractory SE, continuous intravenous midazolam and propofol, separately or in combination, are rapidly effective, with pentobarbital remaining the gold standard for prolonged cases. If a patient does not awaken after treatment, urgent electroencephalogram (EEG) should be obtained to rule out nonconvulsive seizure activity. In refractory SE, continuous EEG monitoring is required to recognize recurrence of seizure activity, as most seizures will be nonconvulsive.