How should status epilepticus be managed?

Status epilepticus, a medical emergency, is the most severe form of epilepsy and frequently occurs in those without any history of seizures. It is defined as continuous clinical and/or electrographic seizures for a specified duration of time, the duration of which differs for different types of status epilepticus. Termination of seizure activity as rapidly as possible is crucial because morbidity and mortality directly correlate with the duration of seizures. Treatment of status epilepticus is directed at terminating seizures as rapidly as possibly using an escalating therapeutic protocol, as well as detecting and treating the underlying cause if possible. Initial treatment with intravenous midazolam or lorazepam, or intramuscular midazolam, is now standard of care with excellent data supporting these treatments as first line. After benzodiazepines have been administered, if seizures persist, additional medication choice should consider patient’s comorbidities because current evidence is lacking as to the most adventitious agent. In most cases intravenous levetiracetam, valproic acid or fosphenytoin are considered the best second agent options. For refractory cases of status epilepticus, general anesthetic agents are administered, and cessation of seizure activity must be monitored with continuous electroencephalography. Functional outcome appears to be dependent on the duration of seizure activity.