Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults

IV lorazepam and IV diazepam are established as efficacious (Level A).

Rectal diazepam, IM midazolam, intranasal midazolam, or buccal midazolam are probably effective and should be considered (Level B).

Non-IV midazolam (IM/intranasal/buccal) is probably more effective than diazepam (IV/rectal) (Level B).

IV valproic acid has similar efficacy but better tolerability than IV phenobarbital and should be considered (Level B).

Respiratory depression is the most common clinically significant treatment-emergent AE (Level A).

Perform standard stabilization: support respiration, maintain blood pressure, gain IV access, and identify/treat underlying causes (Level A).

Administer a benzodiazepine as the initial therapy of choice. Options: IV lorazepam (4 mg), IV diazepam (10 mg), or IM midazolam (10 mg) (Level A).

IM midazolam (10 mg for >40 kg) has superior effectiveness compared to IV lorazepam and is established as efficacious (Level A).

Administer an adequate single full dose rather than multiple smaller doses (Level A).

A second full dose of IV lorazepam or IV diazepam may be repeated once (Level A).

Administer a single dose of: IV fosphenytoin (20 mg PE/kg, max 1500 mg PE), IV valproic acid (40 mg/kg, max 3000 mg), or IV levetiracetam (60 mg/kg, max 4500 mg).

Be aware that second therapy is significantly less effective than the first (7% vs 55% success), and third therapy is substantially less effective (2% success) (Level A).

Consider repeating second-line therapy or anesthetic doses (thiopental, midazolam, pentobarbital, or propofol) with continuous EEG monitoring (Level U).

Monitor for respiratory depression and cardiac symptoms, which are the most common treatment-emergent AEs (Level A).