Generalised

START TIMER - INTITAL SEIZURE MANAGEMENT INITIAL INVESTIGATIONS

Seizure Assess - Airway / Breathing / Circulation • FBC, U&Es, LFTs, Ca2+, Mg2+, clotting studies, VBG, Glucose
0-5 mins • If applicable: bloods for AED levels, B-HCG, Toxicology screen
Start high flow O2 • If no known seizure history or overt trigger: consider neuroimaging
Position patient to prevent aspiration and ensure safety
Establish IV access
IF HYPOGLYCAEMIC (Glucose < 4 mmol/L )
Capillary blood glucose check (1) Give 150-200ml 10% glucose IV over 15mins (i.e. 600ml/Hr)
Monitor vital signs: SpO2 / HR / BP / ECG (2) If seizures continue, repeat step 1 AND commence 10% glucose
infusion at 100ml/Hr.
*If suspicion of alcohol excess or malnutrition give 1x pair IV Pabrinex with IV
glucose replacement
Early SE STATUS EPILEPTICUS – 5 minutes
5-15 mins ≥ 5 minutes continuous generalised seizure activity or CONSIDER IN ALL PATIENTS
≥ 5 minutes recurrent generalised seizures without recovery Collateral History / PPM+ record:
• Identify if known epilepsy +/- seizure care plan
• Medication history (see GP Tab on PPM+)

1st Line treatment - IV Access
Lorazepam 4mg IV bolus or
Diazepam 10mg IV bolus
MONITOR FOR 5 MINUTES - If status
continues at 5 minutes repeat dose
1st Line treatment - No IV Access
Midazolam 10 mg Buccal / IM or
Diazepam 10mg PR
MONITOR FOR 5 MINUTES - If status
continues at 5 minutes repeat dose
Consider aetiology of seizure +/- management of cause:
• Drug intoxication or withdrawal (including alcohol)
• AED issues (poor compliance, poor absorption, recent AED changes,
medication interactions or sub therapeutic levels)
• Infection (Sepsis / CNS infection)
• Metabolic disturbance (electrolytes, glucose)
• CNS pathology (tumour, stroke, encephalitis, PRES,
neurodegenerative diseases etc.)

Consider PNES (Psychogenic non-epileptic seizure) / NEAD (Non-

Established ESTABLISHED STATUS EPILEPTICUS – 15 minutes epileptic attack disorder): If doubt discuss with neurology but continue
Call 2222 - Escalate to ICU / Anaesthetics pathway. Do not use lactate as sole marker of epilepsy vs. NEAD.
SE Ensure IV or IO access established to begin 2nd line treatment as below
15-30 mins Benzodiazepine dosing for low body weight (<40Kg): Lorazepam = 0.1 mg/kg,
maximum 4 mg. Diazepam = 0.2 mg/ kg, maximum 10 mg
2nd Line treatment – AED Loading at 15 minutes
Loading with one of the following IV anti-epileptic drugs (AEDs): Considerations for AED choice

IV Levetiracetam 60mg/kg, maximum 4500mg - In 100ml sodium chloride 0.9% over 10 Avoid if: Behaviour or mood disorder, renal impairment (see BNF),

Levetiracetam
using brivaracetam
minutes Preferred for: Women of childbearing age, polypharmacy (relatively few
drug-drug interactions)
IV Phenytoin 20mg/kg, maximum 2000mg - Give undiluted. Rate 50mg/min or 25mg/min
for elderly or cardiac history. An in-line filter (0.22 microns) should be used. ALWAYS INFUSE
WITH ECG MONITORING. Additional information on loading see link: leedsformulary.nhs.uk Needs ECG monitoring Risk of arrhythmia.

IV Valproate 40mg/kg, maximum 3000mg - In 100ml sodium chloride 0.9% over 5 minutes.
AVOID IN WOMEN OF CHILDBEARING AGE IF POSSIBLE
ONGOING STATUS EPILEPTICUS DESPITE 2nd LINE
THERAPY < 30 minutes
Commence additional IV AED from above list
If no AED suitable from list call neurology registrar
Phenytoin
Avoid if: Known or suspected generalised / genetic epilepsy. Low BP /
HR. Heart block. Porphyria. Overdose of recreational drugs. Alcohol
withdrawal.
Valproate Avoid if: woman of childbearing age, metabolic/mitochondrial disease
(suspected or known), liver failure, pancreatitis, use of carbapenem
Preferred for: known or suspected generalised / genetic epilepsy,. Co-
morbid mood disorder / migraines
At ≥ 30 minutes
move to refractory Alternative AEDs to be considered with neurology discussion only – Lacosamide or
status algorithm Phenobarbital – See Page 3 for details
 REFRACTORY STATUS EPILEPTICUS (RSE) THERAPEUTIC TARGET
Refractory Generalised seizures of >30 minutes duration despite 2 doses of benzodiazepine and at Burst suppression with no breakthrough seizures (clinical or EEG) for 24 -
48 hours
SE least 1 dose of AED.
Manage only in appropriate setting with anaesthetics / ICU input for airway support.
30+ mins These treatments are only to be delivered by clinicians experienced in their use. EARLY CONSIDERATIONS
• Consider neuroimaging
• Correct any metabolic derangement
• Female patients – Ensure pregnancy / eclampsia excluded
3rd line treatment - General Anaesthetic • Continuous EEG / bispectral index (BIS) monitoring, or regular EEGs
1) INDUCTION - Propofol, midazolam, thiopentone or ketamine • Ensure on adequate antiepileptic medication / AED level checked
2) MAINTENANCE - Continuous infusion of propofol and/or midazolam. • Ensure NOK informed and aware of treatment decisions / prognosis
3) CONTINUE AEDs - Ensure newly loaded AEDs and pre-hospital AEDs prescribed on eMEDs
Anaesthetic agent doses Considerations for agents choice

Bolus: 1-2mg/kg Monitor for propofol infusion syndrome

Propofol
Failure of seizure control after 1 hour (PRIS) – ECG, CK, lipid profile, renal function,
Maintenance: oedema. PRIS risk increases with dose.
Check AED levels 0.5-4mg/kg/hour
Consider anaesthetic agent bolus – Propofol or Midazolam
Consider starting additional IV AED – Discuss with neurology on-call if required Bolus: 0.2mg/kg Midazolam interacts with multiple drugs

Midazolam
including AEDS. Can accumulate in renal
Maintenance: failure and obese patients. Tachyphylaxis
0.1mg/kg/hour with prolonged use.
On-going failure of seizure control
Consider infusion with additional anaesthetic agent - see listed agents in grey Bolus: 3-5mg/Kg Very long half life. Prone to accumulation

Thiopental
Liaise with neurology team due to zero order kinetics.
Maintenance:
Liaise with pharmacist 5mg/kg/hour

Bolus: 15 mg/Kg (Max. Slow administration. Can suppress brain

Phenobarbital
Super SUPER REFRACTORY STATUS EPILEPTICUS (SRSE)
100mg) at 50-100mg/min
via pump
stem reflexes. Can suppress immune
system. Slows gut motility.
Refractory Generalised convulsive seizures 24 hours after induction with general anaesthesia. Maintenance:
Seek specialist neurology input.
SE Ensure AEDs and anaesthetic agent doses are optimised.
1-4mg/kg/hour

Bolus: 3mg/Kg Can impair EEG / BIS monitoring.

>24H

Ketamine
Starting maintenance: 1
Treatment options to consider: mg/kg/hour (see titration
in full guidelinetext)

Consider aetiology / investigations: • Magnesium infusion

• Alternative AEDs: NG topiramate, IV Loading: 4g over 15 min Caution in cardiac conduction block, low BP,

• Neuroimaging
• CSF / Serum: auto-immune
encephalitis antibody panel, exclude
occult infection
• Toxicology screen: illicit drugs and
medications which can potentiate
seizures
• Consider paraneoplastic aetiology: CT-
TAP, testicular ultrasound / pelvic
ultrasound, breast imaging
lacosamide, IV phenobarbital.
• Immunomodulation (e.g. high dose
steroids, IV immunoglobulin , plasma
exchange, rituximab)
• Neurosurgical intervention
• Ketogenic diet (ICU dietitian discussion)
• Hypothermia
• Pyridoxine
• Electrical and magnetic brain
stimulation strategies
Magnesium
myasthenia, muscle blocking agents.
Maintenance: 1g / hour Monitor serum Mg2+ levels and deep tendon
to target serum level >3.5 reflexes. Slow rate if bradycardia occurs.
mmol/L
Treatment of SRSE should be guided by neuro-intensive care, neurology,
neurophysiology and pharmacy in an MDT approach.
The management of SRSE does not currently have high quality
randomised controlled trial evidence. Treatments should be reviewed
regularly and if considered to be ineffective they should be ceased to
minimise risk of adverse effects.
 Patient IMMEDIATE MANAGEMENT AFTER STATUS EPILEPTICUS
PATIENTS WHO CLINICALLY REMAIN LOW GCS OR CONFUSED POST
STATUS DESPITE RESOLUTION OF GENERALISED SEIZURE ACTIVITY
care after Reassess - Airway / Breathing / Circulation Commonly post-ictal state – monitor for recovery
Assess GCS - If remains low consider causes (see box to right)
SE Assess for focal neurology
If slow to recover GCS, consider:
• Underlying pathology causing status (e.g. low glucose, alcoholic
Consider aetiology of seizure encephalopathy, illicit drug use, sepsis, stroke, cerebral bleed, CNS
In known epilepsy consider triggers infection )
• Benzodiazepine or AED side effect
• Non-convulsive status epilepticus (especially in elderly - discuss with
neurology +/- arrange urgent EEG )

AED maintenance doses Dose adjustments

ENSURE NEWLY LOADED AEDs CONTINED

Levetiracetam
Prescribe maintenance doses of loaded antiepileptic drugs on eMEDs Commence after 12 hours - 1000mg BD In renal impairment eGFR
(IV to PO conversion = 1:1) <50 review doses with BNF.
See table in right hand side column for dosing If dialysis patient, consult
If using phenytoin, ensure drug level prior to next dose renal pharmacist.

Commence after 6 hours – 100mg TDS If switching to oral liquid,

(IV to PO tablets or capsules conversion = convert dose using formula:
1:1). 100mg phenytoin sodium

Phenytoin
(IV or tablet) = 90mg
Check serum albumin and serum phenytoin base (oral liquid
phenytoin before next dosing as per “LTHT solution).
CONSIDER WHERE TO MANAGE PATIENTS POST STATUS Intravenous Phenytoin for Status
Patients need to be in an environment where they can be observed easily Epilepticus in Adults guideline” - Access
via http://www.leedsformulary.nhs.uk
Discuss location with SpR / consultant in charge of patient’s care
Commence a ‘Seizure Record’ on PPM+ (under clinical documents) Commence after 12 hours – 1000mg BD Avoid in liver impairment

Valproate
(IV to PO conversion = 1:1)
Continue to monitor regularly for further seizure activity over next 24H

Commence after 12 hours – 100mg BD Dose reduction in renal and

Lacosamide
(IV to PO conversion = 1:1) hepatic impairment –
discuss with pharmacy .
Only for use with neurology discussion

INFORM NEUROLOGY Discuss with neurology for dosing Discuss with pharmacy

Phenobarbital
Refer to neurology via Patient Pass
Patients not known to have epilepsy will need ‘First Fit Clinic’ follow up Only for use with neurology discussion

Alternative AEDs loading regimens - NEUROLOGY OR NEURO-ICU APPROVAL ONLY

Lacosamide
• IV Loading dose: 200mg
• Dilute in 50-100mL of 0.9% sodium cholride or glucose 5%.
• Infuse over 15 minutes
Phenobarbital
• IV Loading dose: 15 mg/kg
• Dilute each 1mL ampoules to at least 10mL sodium chloride 0.9% or glucose 5%. Use a 100mL bag for higher injection volumes.
• Infuse at a rate of 100 mg/minute