Pharmacologic Treatment of Generalized Tonic-Clonic Status Epilepticus (SE) in Adults

Pharmacologic Treatment of Generalized Tonic-Clonic Status Epilepticus (SE) in Adults - Flowchart

«Flowchart»

IV benzodiazepine
LZP 0.1 mg/kg, or MDZ 0.2 mg/kg, or CLZ 0.015 mg/kg

IV benzodiazepine

Established and early refractory SE (30 min to 48 h)

IV MDZ 0.2 mg/kg !!RtArrow!! 0.2-0.6 mg/kg/h and/or IV PRO 2 mg/kg !!RtArrow!! 2-10 mg/kg/h

Established and early refractory SE (30 min to 48 h)

IV MDZ 0.2 mg/kg !!RtArrow!! 0.2-0.6 mg/kg/h and/or IV PRO 2 mg/kg !!RtArrow!! 2-10 mg/kg/h

Established and early refractory SE (30 min to 48 h)

IV MDZ 0.2 mg/kg !!RtArrow!! 0.2-0.6 mg/kg/h and/or IV PRO 2 mg/kg !!RtArrow!! 2-10 mg/kg/h

IV MDZ IV PRO

Established and early refractory SE (30 min to 48 h)

Further IV/PO antiepileptic drug
VPA, LEV, LCM, TPM, PGB, or other

Established and early refractory SE (30 min to 48 h)

Further IV/PO antiepileptic drug
VPA, LEV, LCM, TPM, PGB, or other

Established and early refractory SE (30 min to 48 h)

Further IV/PO antiepileptic drug
VPA, LEV, LCM, TPM, PGB, or other

Further IV/PO antiepileptic drug

Impending and early SE (5-30 min)

IV antiepileptic drug
PHT 20 mg/kg, or VPA 20-30 mg/kg, or LEV 20-30 mg/kg

Impending and early SE (5-30 min)

IV antiepileptic drug
PHT 20 mg/kg, or VPA 20-30 mg/kg, or LEV 20-30 mg/kg

Impending and early SE (5-30 min)

IV antiepileptic drug
PHT 20 mg/kg, or VPA 20-30 mg/kg, or LEV 20-30 mg/kg

IV antiepileptic drug

Generalized convulsive or “subtle” SE

Focal-complex, myoclonic or absence SE

Other anesthetics
Isoflurane, desflurane, ketamine

Other anesthetics

Other approaches
Surgery, VNS, rTMS, ECT, hypothermia

Other approaches
Other approaches

Other medications
Lidocaine, verapamil, magnesium, ketogenic diet, immunomodulation

Other medications
Other medications

CLZ, clonazepam; ECT, electroconvulsive therapy; LCM, lacosamide; LEV, levetiracetam; LZP, lorazepam; MDZ, midazolam; PGB, pregabalin; PHT, phenytoin or fos-phenytoin; PRO, propofol; PTB, pentobarbital; rTMS, repetitive transcranial magnetic stimulation; THP, thiopental; TPM, topiramate; VNS, vagus nerve stimulation; VPA, valproic acid.

Late refractory SE (>48 h)

PTB (THP) 5 mg/kg (1 mg/kg) !!RtArrow!! 1-5 mg/kg/h

Late refractory SE (>48 h)

PTB (THP) 5 mg/kg (1 mg/kg) !!RtArrow!! 1-5 mg/kg/h

Late refractory SE (>48 h)

PTB (THP) 5 mg/kg (1 mg/kg) !!RtArrow!! 1-5 mg/kg/h

PTB (THP)

Established and early refractory SE (30 min to 48 h)

IV MDZ 0.2 mg/kg !!RtArrow!! 0.2-0.6 mg/kg/h and/or IV PRO 2 mg/kg !!RtArrow!! 2-10 mg/kg/h

Established and early refractory SE (30 min to 48 h)

IV MDZ 0.2 mg/kg !!RtArrow!! 0.2-0.6 mg/kg/h and/or IV PRO 2 mg/kg !!RtArrow!! 2-10 mg/kg/h

IV MDZ IV PRO IV MDZ

Other medications
Lidocaine, verapamil, magnesium, ketogenic diet, immunomodulation

Other medications
Other medications

Other anesthetics
Isoflurane, desflurane, ketamine

Other anesthetics
Other anesthetics

Other approaches
Surgery, VNS, rTMS, ECT, hypothermia

Other approaches
Other approaches