Benzodiazepine twice, then phenytoin or levetiracetam, then anaesthesia
Expansion
Definition: a seizure lasting 5 minutes or more, or repeated seizures without recovery of consciousness between them.
Stepwise treatment
- 0 to 5 minutes: ABC, oxygen, check glucose, intravenous access, and thiamine if alcohol dependence or malnutrition is suspected
- 5 minutes: lorazepam 4 mg IV, or buccal midazolam or rectal diazepam if no access
- 10 to 15 minutes: repeat the benzodiazepine once. No more than two doses in total
- 15 to 30 minutes: a second line agent, levetiracetam, phenytoin or sodium valproate
- 30 minutes onwards, refractory: general anaesthesia with propofol, midazolam or thiopentone, with intubation and EEG monitoring
“Two doses of benzodiazepine, then move on.” Repeated benzodiazepine doses cause respiratory depression without terminating the seizure.
Look for a cause throughout: hypoglycaemia, hyponatraemia, hypocalcaemia, infection (meningitis, encephalitis), stroke or haemorrhage, head injury, drug or alcohol withdrawal, overdose, eclampsia, and non-adherence to antiepileptics, which is the commonest cause in known epilepsy.
Eclampsia is treated with magnesium sulphate, not the standard algorithm.
Non-convulsive status presents as unexplained confusion or coma and requires an EEG; it is easily missed after an apparently terminated convulsion.