Treatment algorithm for tonic-clonic status epilepticus in adults

Timeline Initial patient management 0-5 minutes Ongoing

• Protect the patient. Do not restrain. management
Give 150-200ml 10% glucose IV stat.
• Consider airway adjunct.
• Administer oxygen.
If seizures continue repeat this step AND Regular observations
• Place patient in a semi-prone position,
commence 10% glucose infusion at
head down 12 lead ECG
100ml/hr.
• Gain IV access
t=0 If suspicion of alcohol excess or Obtain FBC, U&Es, LFTs,
• Obtain BM. If hypoglycaemic malnutrition commence 1 pair Pabrinex IV Ca2+, Mg2+, clotting studies
BEFORE glucose replacement. and if applicable antiepileptic
drug levels and blood gas.

Treat acidosis if severe

1st line treatment 5-15 minutes (discuss with critical care)

Determine if diagnosed
If IV access If no IV access epilepsy, medication history
DOSE 1 – IV lorazepam 4mg bolus DOSE 1 – Buccal midazolam 10mg and acute seizure care plan
(Alternative IM midazolam 10mg)
t=5 Wait 5 minutes Consider neuroimaging and
Wait 5 minutes EEG
DOSE 2 – IV lorazepam 4mg bolus
DOSE 2 – Buccal midazolam 10mg
(Alternative IM midazolam 10mg) Consider possibility of non-
Wait 5 minutes epileptic seizures
Wait 5 minutes
Consider and treat potential
causes:
• Medication related (poor
2nd line treatment 15 minutes onwards compliance, poor
absorption, recent
IV or IO access antiepileptic drug changes,
Escalate to Critical Care as per local policy medication interactions or
subtherapeutic levels)
DOSE 3 • Infection
• Electrolyte disturbance
t=15 IV Levetiracetam 60mg/kg, maximum 4500mg (in 100ml sodium chloride
• Toxicity or drug withdrawal
t=15 0.9% over 10 minutes)
(including alcohol
OR IV Phenytoin 20mg/kg, maximum 2g (rate 50mg/min, 25mg/min for elderly or withdrawal)
patients with cardiac history, give undiluted)
• CNS pathology (tumour,
OR IV Valproate 40mg/kg, maximum 3000mg (in 100ml sodium chloride 0.9% stroke, encephalitis, PRES,
over 5 minutes) neurodegenerative diseases
etc.)
Caution – phenytoin administration requires cardiac monitoring and wide bore
IV access due to risk of extravasation and phlebitis.

Preferred if Avoid if
Levetiracetam - Polypharmacy (fewest - Mood or behavioural disorder (may worsen symptoms)
(Keppra) drug interactions) Seizure
Phenytoin - Cardiac monitoring not available terminated
- Known or suspected generalised epilepsy (genetic
epilepsy)
- Hypotension/bradycardia/heart block
- Porphyria
- Known or suspected overdose of recreational drugs / ABCDE assessment of
alcohol withdrawal.
patient at regular
Valproate - Known or suspected - Women of childbearing potential (consider pregnancy intervals.
idiopathic generalised test)
epilepsy (genetic - Liver disease
epilepsy) - Pancreatitis
Consider escalation to
- Co-morbid mood - Known or suspected metabolic disorder/mitochondrial Critical Care setting if
disorder/migraines disease (risk of hepatotoxicity) indicated

If ongoing seizures following the completion of the infusion consider 2nd IV Start supportive medical
antiepileptic drug infusion of a different drug from the same list (levetiracetam, care and look for
phenytoin, valproate as above) OR phenobarbital. underlying cause of
status epilepticus
Phenobarbital can be given 15mg/kg as a single dose, max. rate 100mg/min.
If at any point >30 minutes since seizure onset move to 3rd line treatment.

Caution when using multiple agents with similar mechanism of action in view of potential adverseReview Date:
effects. See May 2023
Appendix 2.
Version: 1.0
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