Status Epilepticus

Definitions

Status Epilepticus: generalized convulsive epilepsy lasting more than 5 minutes or 2 seizures with a intermittent period where the patient doesn’t clear.

Refractory Status Epilepticus: resistant to 2 anticonvulsants

Super-refractory Status Epilepticus: resistant to 2 anticonvulsants and general anesthesia

Treatment

0 minutes

  • IV Ativan .1mg/kg (2mg/min) or IM Midazolam 10mg (if>40kg)
  • IV Keppra 60mg/kg give through second IV
  • Check sugar
  • Place on NRB
  • End tidal CO2

5 minutes

  • If still seizing give Ketamine 1mg/kg (per Farkas and Weingart)
  • Can also give a repeat dose of Ativan (0.1mg/kg) per Uptodate

10-15 minutes

  • Intubate
  • Propofol 1.5mg/kg
  • Ketamine 3mg/kg
  • Paralytic
Screenshot

March 2025 Emcrit

  • Early Ketamine for Status
  • Weingart says add Ketamine with second dose of Midazolam (4-6mg) at 5 min if first dose of Midazolam (2-4mg) doesn’t work. Weingart likes Midazolam better because he thinks it works a little faster and it wears off so you can reassess the patient.
  • From Othman et al. Paper: Participants with seizures lasting beyond the 5-min stabilization phase received 0.4 ml/kg (max 12 ml) over 2 min of the randomly assigned study drug (equivalent to ketamine 2 mg/kg (max 60 mg) in case of active drug) simultaneous with midazolam 0.2 mg/kg
  • Cessation of clinical seizures at 5-min occurred in 76% of children in the Ket-Mid group compared with 21% in the Pla-Mid group (Risk ratio [RR] 3.7; 95% confidence interval [CI] 2.3-5.9; p <0.001). Compared with the Pla-Mid group, the Ket-Mid group had higher percentages of seizure cessation at 15-min (76.4% vs. 23.6%; RR 3.2, 95%CI 2.1-5.0), 35-min (83.3% vs. 45.8%; RR 1.8, 95%CI 1.4-2.4), and 55-min (88.9% vs. 72.2%; RR 1.2, 95%CI 1.04-1.45) study timepoints as well as lower percentages of repeating midazolam (23.6% vs. 79.2%; RR 0.3, 95%CI 0.19-0.46) and endotracheal intubation (4.2% vs. 20.8%; RR 0.2, 95%CI 0.06-0.66). Both groups showed no significant differences in other outcome measures.
  • Othman, Amr A., Abdelrahim A. Sadek, Esraa A. Ahmed, and Elsayed Abdelkreem. “Combined Ketamine and Midazolam vs. Midazolam Alone for Initial Treatment of Pediatric Generalized Convulsive Status Epilepticus (Ket-Mid Study): A Randomized Controlled Trial.” Pediatric Neurology, March 22, 2025. https://doi.org/10.1016/j.pediatrneurol.2025.03.011.
  • Zitek, Tony, Kenneth A. Scheppke, Peter Antevy, Charles Coyle, Sebastian Garay, Eric Scheppke, and David A. Farcy. “Midazolam and Ketamine for Convulsive Status Epilepticus in the Out-of-Hospital Setting.” Annals of Emergency Medicine 85, no. 4 (April 1, 2025): 305–12. https://doi.org/10.1016/j.annemergmed.2024.11.002.