EFNS Guideline On The Management Of Status Epilepticus.
Link to this: http://www.efns.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2006_management_of_status_epilepticus.pdf
This document was developed by a task force comprised of 7 neurologists organized by the European Federation of Neurological Societies (EFNS), a consortium comprised of 43 European national neurological societies based in Austria. The development process was carried out in accordance with a preparation document generated by the EFNS in 2004.5 The group designated a single member to carry out the literature search according to reported parameters. Evidence was evaluated for quality based on criteria specified in the preparation document and sorted into 4 classes (I, II, III, IV). Recommendations were graded (A: established as effective; B: probably effective; C: possibly effective; GPP: the opinion of the panel reported as good practice points "where there was a lack of evidence but consensus was clear") based on the strength of evidence for each question.
A funding source is not identified. Panelists' conflicts of interest were reported as none declared. The target is identified as adults with status epilepticus "in critical care situations." Debate around the definition of status epilepticus is described; studies on patients with seizures lasting 5, 10, and 30 minutes were included. Recommendations in this document are reported in narrative style; those recommendations that pertain to emergency medicine are summarized here.
General initial management
Recommendation 1 (Level GPP): Support airway and ventilation; monitor blood pressure and ECG waveform; perform blood gas analysis; supplement glucose and thiamine as required; and measure and monitor serum antiepileptic drug levels, electrolytes (including magnesium), blood counts, and hepatic and renal function. Identify and treat the underlying cause.
Initial pharmacological treatment of generalized convulsive status epilepticus (GCSE)
Recommendation 2 (Level A): Treat partial status epilepticus and GCSE with lorazepam 4 mg IV; repeat in 10 minutes if seizures persist. Phenytoin 15 to 18 mg/kg or equivalent fosphenytoin is recommended "if necessary." An alternate regimen is diazepam 10 mg IV followed by phenytoin 15 to 18 mg/kg or equivalent fosphenytoin; repeat diazepam in 10 minutes if seizures persist.
Pharmacological treatment for refractory GCSE and subtle status epilepticus
Recommendation 3 (Level GPP): Infuse anesthetic doses of midazolam, propofol, or barbiturates titrated against an EEG burst suppression pattern. Initiate treatment with non-sedating antiepileptic agents simultaneously. Thiopental: 100 to 200 mg bolus over 20 seconds with 50 mg boluses every 2 to 3 minutes until seizures are controlled, then infusion 3 to 5 mg/kg/hr. Pentobarbital: 10 to 20 mg/ kg bolus followed by an infusion of 0.5 to 3 mg/kg/hr. Midazolam: 0.2 mg/kg bolus followed by an infusion of 0.1 to 0.4 mg/kg/hr. Propofol: 2 mg/kg bolus followed by an infusion of 5 to 10 mg/kg/hr.
Pharmacological treatment for non-convulsive status epilepticus (NCSE)
Recommendation 4 (Level GPP): Ongoing NCSE is less dangerous than GCSE; therefore, non-anesthetizing anticonvulsants may be tried initially. Phenobarbital: 20 mg/kg IV. Valproic acid: 25 to 45 mg/ kg IV infused at a maximum rate of 6 mg/kg/min.
Full Guideline: http://www.efns.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2006_management_of_status_epilepticus.pdf