Gw status epilepticus protocol Applies to



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GW Status epilepticus protocol

Applies to:

Any adult patient (>40 kg) with:

Generalized tonic clonic seizures or focal seizures with altered awareness and at least one of following:


  • Witnessed seizure lasting > 5 mins or ones with unwitnessed onset ongoing at the time treating physician assesses the patient

  • 2 seizures occurring over >5 min without intervening recovery of baseline mental status



0-5 mins

Supplemental O2, ABCs, IV access​, EKG, VS




Comprehensive metabolic panel, CBC, Anti-Seizure Medication (ASM) levels, tox screen, hCG, troponins

Consider thiamine 100 mg IV+ 50 mL D50 blood glucose (if applicable)

Emergent initial therapy

- IV lorazepam 0.1 mg/kg, OR

- IM or IV midazolam 0.15 mg/Kg

AND


Order IV Anti-Seizure Medication

5 – 15 mins

IV Anti seizure medication:
1. Levetiracetam – 3000 mg IV load (if renal function is normal, 2 g for Cr between 1 and 2, and 1 g for Cr >2),
If status/seizures is still ongoing after 5 minutes of LEV, give
2. Lacosamide – 400 mg IV load
and

Order Propofol or midalozam



15- 20 mins

Secure airway

Vasopressor support if needed

Non contrast head imaging

Give propofol IV OR Midalozam (see doses below)

Transfer patient to ICU

Order cEEG

Consult neurology


Ongoing SE on cEEG (refractory)

Maximize iv anesthetic/ add ketamine to midazolam

Add third anti seizure medication –

Valproate – 30 mg/kg IV load


Ongoing SE (super-refractory

If seizures still persists despite 2 anesthetics and 3 anti-seizure medications

Switch to pentobarbital

Add 4th ASM

fosphentoin

Phenobarbital *failure to wean pentobarb

Clobazam

Topamax

** Consider alternative therapy - ketogenic diet or immune therapy ( to be recommended by epilepsy)




Status resolved on cEEG

Maintain seizure freedom for 24 – 48 hours followed by slow wean of cIV medications



Weaning protocol

Midazolam: over 6-12 hr​

Propofol : over 12-24 hr​

Pentobarbital : over 12-24 hr or stop the cIV

Ketamine: wean over 12 hours prior to starting midazolam wean

Failure to wean

(Frank clinical seizures resume Or ​continuous or frequent electrographic seizure resume (>1 sz/hr)) .

Immediate resume prior cIV at prior dose

AED dosing

Levetiracetam : 2000 mg IV load, may repeat if necessary (followed by 1.5 g IV BID)​

Lacosamide :400 mg IV load (followed by 200 mg IV BID)​

Valproate :30 mg/kg IV load over 10 mins (followed by 15 mg/Kg IV BID)​

Level – 80 – 100 mg/ml



Foshenytoin :20 mg/kg IV load up to 50 mg/min

Maintainence : 5 mg/mg in 3 divided doses every 8 hours

Level :15-20 mcg/ml

Topiramate :no load , 200-400 mg pNG q12 h​,

Level : 20 – 20 mcg/ml, watch HCO3



Phenobarbital ​:*consider if failure to wean pentobarbital

Load 15-20 mg/kg​

Maintainence :1-4 mg/kg/d PO/IV div q6 or q8h​

Level – 30 – 50 mcg/ml



Clobazam : No load, 20 mg q12h pNG

cIV dosing ​



Propofol : Load - 1-2 mg/kg over 3-5 min; repeat every 5 mins until clinical seizures have resolved (max 10mg/kg)​

Initial cIV rate – 20 mcg/kg/min;increase by 10mcg/kg/min after each bolus ​

cIV range 10 – 80 mcg/kg/min​

Midazolam:Load : 0.2 mg/kg; repeat every 5 mins until clinical seizures resolve (max 1mg/kg)​

Initial cIV rate : 0.2 mg/kg/hr; incrase by 0.2 mg/kg after each bolus ​

cIV range : 0.2-2 mg/kg/hr

Pentobarbital: Load : 5mg/kg upto 50 mg/min: repeat as needed until cEEG shows bursts suppression

Initial cIV rate : 0.5 mg/kg/hr ​

CIV range : 0.5-10 mg/kg/hr

Ketamine: Load 1 mg/kg as Bolus; repeat every 5 minutes as needed

Initial cIV rate 5 mcg/min



cIv range 5-100 mcg/min


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