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Algorithm for acute management of status epilepticus

Status epilepticus is considered present if generalized convulsive seizures or successive seizures without return to baseline last for more than 5 minutes. Rapid hemodynamic stabilization and IV access should be initiated followed by immediate administration of first line treatment. Basic blood tests like glucose should be done to correct for reversible causes. This also includes sub therapeutic level for AEDs that the patient is taking. Further evaluation of etiologies like brain imaging or CSF analysis should proceed as the patient receives the successive tiers of management. Refractory status epilepticus occurs if the seizures do not respond to secondary management. Initiation of pharmacologically induced coma should be guided by VEEG to burst and/or seizure suppression. Hemodynamic support with fluids and/or pressors may be needed with propofol, benzodiazepines (midazolam), or barbiturates (pentobarbital). Super refractory status epilepticus (SRSE) occurs when seizures persist despite 24 hours of pharmacologically induced coma. Other tertiary consideration for super refractory status epilepticus include therapeutic hypothermia, ketamine, surgery, ketogenic diet, and other treatments. Most CBC=complete blood count; BMP=basic metabolic profile; LFT=liver function test; VEEG=video EEG. (Contributed by Dr. Robert Beach.)