Adult Status Epilepticus

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the September 2025 Emergency Medicine Practice article, Emergency Department Management of Patients With Status Epilepticus

 

Topic Introduction

• Focus: Status Epilepticus in Adults
• Reference to recent pediatric episode
• Article authors: Dr. Marquez, Dr. Kaur, Dr. Lay

Why Status Epilepticus Matters

• Teaching value and clinical challenge
• Team-based care and multidisciplinary involvement

Guidelines and Evidence

• Review of major guidelines (International League Against Epilepsy, Neurocritical Care Society, American Epilepsy Society)
• Key trials: EcLiPSE, ConSEPT, ESETT
• Updated definition of status epilepticus

Classification and Diagnosis

• Convulsive vs. non-convulsive status
• Importance of repeated neurologic exams
• Diagnostic challenges and mimics (e.g., syncope, psychogenic seizures)

Etiology and Workup

• Acute vs. non-acute causes
• Common triggers: medication noncompliance, metabolic issues, infections, trauma
• Importance of sleep patterns and ammonia levels
• The NORSE acronym (new onset refractory status epilepticus)

Prehospital and ED Management

• Airway, breathing, circulation priorities
• Early pharmacologic intervention (IM midazolam preferred in prehospital)
• Gathering history and medication information
• Positioning and airway protection

Diagnostics

• Laboratory workup: glucose, CBC, metabolic panel, drug levels, pregnancy test
• Imaging: non-contrast CT, MRI, ultrasound, lumbar puncture
• EEG: spot vs. continuous monitoring

Treatment Approach

• First-line: Benzodiazepines (lorazepam, midazolam)
• Second-line: Levetiracetam, valproate, fosphenytoin, phenobarbital, lacosamide
• Third-line: Continuous infusions (midazolam, propofol, pentobarbital, thiopental, ketamine)
• Dosing pearls and importance of rapid escalation

Special Populations

• Pregnancy (eclampsia: magnesium as first-line)
• Substance-induced status epilepticus (e.g., isoniazid toxicity and pyridoxine)
• Brief mention of pediatric management and the PD stat app

Risk Management Pitfalls

• Non-convulsive status is common and easily missed
• Importance of weight-based dosing
• Need for formal EEG in ambiguous cases
• Don’t assume non-adherence is the only cause in known epileptics
• Always consider higher level of care for status patients

Clinical Pathway

• Stepwise approach to medication and escalation
• Emphasis on having a pathway/checklist for these high-stress cases

Conclusion

• Recap of key points
• Thanks to authors and listeners
• Reminder to visit ebmedicine.net for CME and resources

Emergency Medicine Residents, get your free subscription by writing [e-mail]

Episode Transcript

T.R. Eckler (00:00):
my favorite acronym from this whole article is NORSE, the patients

(00:04):
that don't respond to the initialrounds of anti-seizure medications.
I like the idea that these patientsthat I find really challenging are
like tough old Vikings and that's whyI have to really battle with them.

Sam (00:15):
Hi everyone, and welcome to another episode of EMPlify
I'm your host, Sam Ashoo.
Before we dive into this month's episode,I want to say thank you for joining us.
I sincerely hope that you find it tobe helpful and informative for your
clinical practice, and I want to remindyou that you can go to ebmedicine.net
where you will find our three journals,Emergency Medicine Practice, Pediatric

(00:36):
Emergency Medicine Practice, and EvidenceBased Urgent Care, and a multitude of
other resources, like the EKG course,the laceration course, interactive
clinical pathways, just tons ofinformation to support your practice
and help you in your patient care.
And now, let's jump intothis month's episode.
Alright, ladies and gentlemen, welcomeback to another episode of EMPlify.

(01:00):
I'm your host, Sam Ashoo, and onthe other end of the microphone.

T.R. Eckler (01:04):
TR Eckler back to talk about my favorite topic, which is
seizures and status epilepticus.

Sam (01:10):
Nice, nice.
If you are not a regularlistener, well then you should be.
But if you are not, then we actuallydid an article on this topic in
children recently, the pediatricstatus epilepticus, and today we
have the pleasure of the follow-up,which is emergency medicine
practice September, 2025 issue on.

(01:33):
Status epilepticus in adults,this one, Dr. Marquez, Dr. Kaur,
and Dr. Lay were the authors forand it is an interesting topic.
You've seen many cases ofadult status epilepticus.

T.R. Eckler (01:46):
I would tell you that this is one of my favorite things to teach
to students and residents, and I findthat trying to stop seizures, especially
status where like the first line agentsaren't working, and then trying to decide
who's in non convulsive status is such agreat challenging question that requires
like great history, great communicationwith EMS, great physical exam and just a

(02:09):
continued, you know, high level of concernand a high level to reassess the patient
and see if they're improving or not.
It's just a great distillation ofwhat doing this job well looks like.
And I think it's a great thing thatinvolves so many different aspects of
the team from, you know, nursing to thetech that does the EEGs to lab to send

(02:30):
out labs for seizure medication levels.
It's just such a great thing that justteaches you how to work in this system
and how to do the best you can for people.

Sam (02:40):
Yeah, and honestly my favorite portion of this article is the
International League Against Epilepsy.
Once again, I get to talkabout my favorite organization.
If you're out there and you belongto the International League Against
Epilepsy, I'm still waiting for my T-shirt

T.R. Eckler (02:57):
T-shirts, we want T-shirts.
Yes.

Sam (03:00):
I wanna be a member of the league.
I love the name of this organization.

T.R. Eckler (03:04):
Let us make your t-shirts.
Just literally, we will start makingt-shirts 'cause they're gonna be amazing.

Sam (03:10):
Grant me the license.
I was happy to see that the authorsdid an exhaustive review of the
literature, like over 75 articles, andthen also pulled guidelines from the
International League Against Epilepsyand the Neurocritical Care Society
and the American Epilepsy Society.
And for the most part, allof these guidelines are in

(03:31):
agreement, which is great.
Interestingly, most of the evidencecomes from 2019 to now because of three
major randomized controlled trials,which the authors mentioned EcLiPSE,
ConSEPT, and ESETT or ESETT dependingon how you pronounce that but all
three of them were good randomizedcontrol studies comparing different
medications for status epilepticus.

(03:53):
And then the authors did a good jobof reminding us about the change in
definition for status epilepticus.
So if you're old, and I will saylike me, you remember when status
epilepticus used to have thedefinition of 30 minutes of continuous
seizing, which is utterly ridiculous.
No one ever waited that long tomake that diagnosis, but that

(04:14):
was part of the definition.
Now it is continuous seizing orseizing without return of normal
mentation before the next one beginsfor five minutes or more in order
to qualify for that diagnosis.
And I think that is a much morereasonable timeframe because I'm not
fond of just sitting around watchingsomebody seize on and on and on.

(04:37):
And we we don't like that experiencein the emergency department.
So a good reminder thatthat definition changed.
If you're a younger physician, youprobably learned this in residency
or even in medical school, honestly.
But if you're an older physician,you may remember that it used to be a
longer period, and really the reasonit is because of the morbidity or
mortality, which is up to 30% forstatus epilepticus considered to be

(05:02):
the most extreme form of seizures.
And that's a pretty highmortality rate, honestly.
So things to keep in mind when wetalk about status epilepticus are
the classification for seizures.
And this gets into some of thenuance that you probably rely on
your neurology colleagues for most.
But TR you already touched on this.
You've got the convulsiveand the non convulsive types.

(05:25):
And if they're convulsing, youcan see evidence of a seizure,
whether that's generalized or focal.
And if they're non convulsive, thisis where it gets to be really quite
difficult to make the diagnosis.
Because if they started with aconvulsive seizure and now are no longer
seizing, but they're altered and theyhaven't regained consciousness, you're
wondering, eh, is there still continuingnon convulsive seizure activity?

(05:48):
Or sometimes it can just present withaltered mentation, bizarre behavior,
unusual things like hallucinationsand bizarre thoughts or a change
in their normal personality.
These are kind of scary thingsbecause they're very easy to miss,
and I think the authors did a greatjob of driving that point home too.

T.R. Eckler (06:05):
And I think repeated neurologic exams is really
what I took away from that.
It's like there's sucha wide range of these.
It's something whereyou're gonna medicate 'em.
Then you've gotta wait and kind ofsee, because yes, the seizures have
stopped, but now you wanna be ableto say to whoever you're kind of
bringing this patient to next, whatdoes their neuro exam look like now?
How has it changed afterwards?

(06:26):
What's different?
Are they back to baseline?
If they're not, what else is going on?
So I just, I liked how they, they kind ofstarted to break this out into categories,
but I find that so much of it is just youreassessing the patient and trying to see
where this is going on you as it develops.

Sam (06:40):
Yeah, yeah.
This is definitely somebody you'renot gonna walk away from and leave the
bedside for any kind of duration of time.
It's gonna take a lot of effort.
And they're usually prettycritical patients, honestly.
They're going to the ICU, they'regoing to neuro ICU, labor intensive.
There's a lot of resources involvedin this evaluation and treatment plan.
On page four, table one does a goodjob of breaking down the classification

(07:03):
for the International League AgainstEpilepsy's classification scheme.
I don't really we want to get into it.
It's a little complex.
And again, this is probably a greatdiscussion with your neurologist, but it
talks about things like the semiology,what it looks like when they're seizing,
the etiology, if it's structural ormetabolic, what the EEG findings are,
and then what the age of the patient are.

(07:24):
Those are all the four axes thatgive you the classifications for
what kind of seizure this was.
But for the relevant portion of the EDevaluation, it is, are they still seizing?
Do we think they're having convulsiveor non convulsive status, and how
do we go about addressing that?
When we talk about the etiology forseizures, there are lots of different

(07:45):
things when it comes to the causes, acuteand non-acute, and I thought this was
an interesting breakdown of definitions.
So, acute etiologies would beanything within the past seven days
that may have triggered the seizure.
All things like abnormalities of sugar andosmolality and electrolyte abnormalities
and things like noncompliance withmedication if they have a history of

(08:07):
seizure disorder or head trauma orinfections or even cerebrovascular
events within the last seven days.
And then the non-acute isanything farther out from that.
And that's the most important distinction.
And interestingly, the authors didmention that, you know, almost half the
cases, we don't ever figure out why thisoccurred even in status epilepticus.

(08:27):
So even in the most extreme formof seizing, despite all of the
tests we can run, about 45% ofthe time, we're not figuring out
what it is that caused this event.

T.R. Eckler (08:37):
I took away from this section just a couple of things that
I thought added to my workup for thesepatients, which is, I wasn't thinking as
much about asking about sleep patternsfor these patients, but I think in
this day and age, especially givenhow much caffeine people are taking.
Especially given the prevalence of,you know, more and more stimulants that
people are using for ADHD, I think thatsleep is not at an all time high in

(08:59):
terms of how well people are sleeping.
So I think that that's something I'm gonnastart at least looking more at to see.
And then I also think I wasn't lookingat ammonia levels as something that
that was gonna cause seizures, andI think that that's gonna be more
on my workup for these patients.
I would like to know that my favoriteacronym from this whole article is
NORSE, the patients that don't respondto the initial rounds of anti-seizure

(09:22):
medications, and therefore they'rediagnosed with new onset refractory status
epilepticus, I like the idea that thesepatients that I find really challenging
are like tough old Vikings and that'swhy I have to really battle with them.
So I find that that's like areally just a, that's got a
lot of layers to that acronym.
I don't like SE for statusepilepticus, I just want them
to commit to calling it status.

(09:43):
'Cause like they've got statusover status migrainosus, no one's
talking about migraine status.
So status is status and I thinkthey should just stick with that

Sam (09:52):
Unless you're talking to a pulmonologist, then it's asthma.

T.R. Eckler (09:55):
Status asthmaticus.

Sam (09:56):
I mean, there is another one.

T.R. Eckler (09:58):
No, I still think status is seizures as much as pulm wants it.
Everyone, everyone wants it.
No, it's, it's seizures.
I'm calling it.
That's it.

Sam (10:07):
It is kind of reminiscent of like acute chest syndrome being ACS.
Right?
And you're like, no ACS is taken already,I'm sorry, that's acute coronary syndrome.
You
can't use that acronym.

T.R. Eckler (10:15):
Like severe asthma exacerbation, critical asthma
exacerbation, however you want gofor that, but status is is seizures.
That's it.
I'm calling it.

Sam (10:23):
Table four on page six goes through some of the known
causes of status epilepticus.
So obviously in the acute phase, ifthey're already on seizure medications,
then if they're not taking them,that's one of the primary causes.
So, non-compliance with medications, thereis the, the idiopathic, we have no idea
what it is that's causing this category.

(10:44):
Drugs.
Lots of drug interactionscan lower seizure thresholds.
So ask about recent prescribing history.
Have they started any new medications?
Are they on antibiotics?
Have they had any recent illnesses?
Because not just the medications totreat those illnesses, but the illnesses
themselves can also trigger seizures.
Like you mentioned, sleep disturbances.
That can happen if you're sick.

(11:04):
Fever, inflammatory reactions,all of these things.
And then the medications weprescribe them for those symptoms.
Metabolic issues, structuralcauses, toxins, certainly, whether
their exposures or intentional orunintentional, infections, and then
intrinsic conditions with knownepilepsy, like you mentioned, sleep

(11:24):
deprivation being the primary one there.
And then there are some remote causes.
So these are things that would beconsidered maybe non-acute, even
outside of seven day time period.
Things like post-traumatic,post encephalitic, post-stroke.
Anytime there's any kind of neuroinjury, patients are at higher risk
for seizures and status epilepticus.
Progressive etiologies like brain tumors.

(11:46):
Myoclonic epilepsy syndromes and dementiasand neurodegenerative conditions.
Those are all things that will makeyou more prone to new onset seizures
and status epilepticus as well.
And so it's a good differential tokeep in mind when you are treating
someone with status epilepticus.
And then table five also includesspecific diagnoses that can cause status

(12:10):
epilepticus, including things likeintracranial hemorrhage, hypoglycemia,
acute hydrocephalus, metabolicderangement of sugar and electrolytes,
drug toxicities and withdrawal.
So we didn't mention that onealready, but alcohol withdrawal,
amphetamine, the stimulant withdrawals.
Syncope is an interesting one.
It's in the differential for statusepilepticus, but it kind of is a

(12:32):
good reminder that there are otherthings that can be seizure mimics,
and we'll get to that in a moment.
Psychogenic, non-epileptic seizures.
Those can be very difficult differentiatefrom true seizures and often require
things like video EEG monitoring sothey can see what's going on with
the patient while looking at the EEG.

T.R. Eckler (12:51):
Sometimes they're easy, Sam, sometimes they're not.
Not easy.
Sometimes the patient starts doing afake seizure and you can yell really loud
their name and they'll stop and look atyou and you can say, hi, welcome back.

Sam (13:02):
Yeah.

T.R. Eckler (13:02):
Doesn't seem like that was a seizure.
And then it's a good time forthe family to talk about that.
But sometimes people do reallyconvincing seizures that aren't
seizures, and it's tricky.
So I don't think people should feel anysort of way that like they definitely
know a seizure is psychogenic or not'cause I think sometimes upstairs teams
will be kind of questioning of that,but it is not always easy to tell.

(13:24):
But sometimes you can.

Sam (13:25):
Yeah.
And that, you know, the psychogenicnon-epileptic seizures are not
necessarily synonymous with malingering.
So you know the intentis not necessarily there.
It's not that the patient istrying to fool you into the fact
that they're having a seizure.
It's just that they have thismanifestation that looks like a seizure,
and we're trying to determine the intent.
And so that's where that namecomes from, that it's psychogenic.

(13:47):
It's not necessarily epileptiform orabnormal electrical activity of the brain.
But yeah, you're right.
And the authors, we'll get into this ina second in the physical exam section,
they did talk about some things thatare typical of a true seizure and
typical of a non-epileptic seizure.
Movement disorders, dyskinesias, severeParkinson's disease, and Guillain-Barré
syndrome, all things that should stayin your differential diagnosis when

(14:10):
you're thinking about status epilepticusbecause they can increase tone and kind
of present with status epilepticus mimics.
So things to keep in mind.
The authors did do a good job,I think, of addressing syncope.
So, syncope, the loss of consciousness,often comes with some shaking
and some, you know, seizure-likeactivity, and then the person regains
consciousness, and then there's nocontinued altered mental status.

(14:32):
As soon as they wake up, they're better.
And that tells you, okay,this wasn't a true seizure.
This was just bad perfusion to the brain.
We weren't getting enough bloodfor a few seconds, hopefully.
The description of the tonic-clonic,jerking, tongue biting, mouth
clenched, eyes deviated.
Those are the kinds of things you'regonna elicit from history from a

(14:53):
bystander that will kind of sendyou down the, the seizure route
instead of a mimic like syncope.
In the pre-hospital setting there are some key things that the authors pointed
out that our pre-hospital colleaguesshould be doing and would be helpful.
Number one is always airway,breathing, and circulation.
Number two is pharmacologictreatment to abort the seizure.

(15:14):
So this kind of seems like ano-brainer, but we're not just
gonna wait for the seizure to end.
We're gonna give somethingto terminate the seizure and
hopefully prevent a second one.
Number three is preventing additionaltrauma to the seizing patient.
So this can happen when someone isseizing and falls off a couch or someone
is seizing and falls out of a chairand smacks their head on the glass
table on the way down on the floor.

(15:35):
Or if they're in the EMS stretcher andthey haven't been completely secured and
they start to have another seizure again,they fall fall off the stretcher while
you're moving them out to the ambulance.
You know, those things do happenand you just gotta be super careful.
If they've had one seizure,they may have another one.
So you gotta anticipate that.
And lastly, the fourth item was gatheringavailable medical history from the
scene, including medications, pillbottles, and signs of drug use, right?

(15:59):
So in addition to getting the historyfrom any people that are around, you're
gonna wanna look for all of thoseitems because they can clue you into
what may be the cause, and that's veryhelpful information to us in the ED.

T.R. Eckler (16:11):
I would add family contact information to that.
'cause I always wanna try to getsome kind of story from family.
Like, Hey, is the patientreally taking their medications?
What seizure meds have they respondedwell to in the past, if you know which
ones did they not respond well to?
I find that directs a lot ofmy therapy more often than not.

Sam (16:27):
Yep.
I thought also the authors did a good jobreminding us that because of suppression
of the gag reflex during statusepilepticus, the patient should be placed
in that left lateral decubitus position.
This can be really hard ifthey're actively seizing.
But something to think about, evenif it's a little bit of a tilt
and shove a few pillows underneaththem and that it's not recommended

(16:48):
to stick anything in their mouth.
Right?
You don't wanna put in a bite blockor try and force open a clenched
jaw, you will lose fingers that wayif you are a paramedic or an EMT or
even a first responder of any sort.
So don't go putting anything into aclenched mouth, just turn 'em on their
side and a little supportive care.
If you do have to give them somethingbecause of hypoxia or their respiratory

(17:10):
drive is not very good, you can usea nasal pharyngeal airway, you know,
that's a, that's a good device.
Goes in the nose and goes all theway to the back of the pharynx,
gets that tongue outta the way andhelps with hypoxia sometimes, and
then a little supplemental oxygen.
And then you follow your ACLS protocols.
So obviously if all of that doesn'twork and you have to medicate and
intubate, that's what you gotta do.
So you get aggressive andyou get aggressive quickly.

(17:33):
Point of care blood sugar is very, verycritical in this scenario because that
can be an easily fixable cause for statusepilepticus that you don't wanna miss.

T.R. Eckler (17:44):
You lose points for intubating hypoglycemic people.
That's always a negative one point.

Sam (17:48):
Yeah.
And then IV access.
This is very helpful, especially if you'regonna go down the ACLS protocol pathway.
But you know, if you are unable to getit, there are IM intranasal options.
IO.
There's all kinds of othermethods for access that are
available to you pre-hospital.
So you guys are the experts when itcomes to that and staying adept at using

(18:11):
all of those tools and knowing whichmedications, especially like midazolam,
which can be given just about in any wayyou could possibly get it into the body
is very effective in terminating seizures.

T.R. Eckler (18:21):
I am falling out of love with intranasal medications 'cause
I find that often I don't get allof the medicine in that I want to.
And I think that they made a greatcase in this article for the efficacy
based on research and trials ofintramuscular midazolam, especially in
the pre-hospital setting, where beforeyou're even worried about getting the
IV, if they're seizing you check thesugar, bang, give 'em some midazolam

(18:45):
because then you're gonna stop them.
And I think the majority ofcases it was even more effective,
I think, than IV lorazepam.
So I took that as likegood drug, short acting.
I think intramuscular is a good, safeway to give that drug 'cause I think it
comes on in a nice fashion that doesn'tusually gimme respiratory depression.
And I think that that was my bigtakeaway from pre-hospital or from if

(19:05):
they get to the ER and I don't have anIV, that's where I'm gonna go first.

Sam (19:07):
Yeah.
Yeah.
I mean, if you have never triedto put an IV in someone in the
back of a truck, imagine them nowseizing while you're doing that.
It's just, it seems impossible.
Somehow our pre-hospital colleaguescan still get them which is amazing and
a testament to their skill, honestly.
But yes, by all means, give themthe IM midazolam and then go after

(19:28):
the IV when they've stopped seizing.
It'll just make it that much easier.
And hopefully that's already in yourpre-hospital protocols for treating
status epilepticus or a seizure.
So yes, midazolam, check theblood glucose, get the history,
bring them on over to the ED.
And the dosing is written therein the article for adult and
pediatric dosing for IM Midazolam.

(19:50):
It is perfectly safe and theauthors did note it terminates
seizures 73% of the time versus IVlorazepam, which was 63% of the time.
And you know, it seems likethat's only a 10% change, but that
was statistically significant.
So it's worthwhile.
And if it's gonna delay stoppingthe seizure, just give it to 'em
IM And then try and get your IV.

T.R. Eckler (20:11):
I took that away from this article too, in the, the theory
and some of the pathophys they talkedabout, that the longer you wait to
give medication, the more likely itis to not be successful in terminating
a seizure in a patient with status.
And I think that made me more inclinedto get benzo into the person as fast
as as I can, and I think intramuscularMidazolam seems like that's the way.

Sam (20:31):
That was a great discussion that we didn't really touch on.
But the pathophysiology there is thatthe longer that the brain is seizing,
the more changes in biochemistry youget, the receptors that are on the
outside of the cells are downregulated.
Those GABA receptorsare starting to go away.
And so the medication, the benzos thatwe give that are supposed to attach to
those receptors, just have less targets.

(20:53):
So the longer you wait, the moreineffective those medications get and
the more likely you are to head downthe intubation and, you know, initiate
a coma route, which is the ultimatething that we're trying to avoid, but
is sometimes necessary in these cases.
Okay.
When they get to the emergencydepartment, the history we touched
on is very, very important.
So assuming you have the time andthere's family available or some other

(21:16):
resource, you want to ask about allof these things we just mentioned,
toxin exposure, recent trauma,recent hospitalizations for stroke.
Do they have a brain tumor?
Is this a known problem?
Is it a new problem?
All of these questions you're gonnaask, and hopefully if they come by
ambulance, EMS is gonna provide youwith the answers to most of these.
And then when we get to the physicalexam portion, this is where now you're

(21:38):
starting to do those serial examsagain and again and again to look for
changes over time as they're seizing.
You're gonna note what kind of seizure.
It's very helpful, I think, for ourneurology colleagues to note the
laterality of the seizure activity.
So if it's not just a completelygeneralized seizure and it's focal,
making a note of yes, it was theirleft arm and their left leg that

(21:59):
was hypertonic and shaking andhad some tonic-clonic activity.
But their right side seemed completelyflacid and their eyes were deviated,
you know, to the left or to theright, those are kind of important
things to note because they canbecome clues that you need to then
chase something down with imaging.
And we'll talk aboutthat in just a second.

T.R. Eckler (22:18):
I would add that I think it's important to ask family too,
is this what their seizures usuallylook like or is this different?
Because if it's different, then I thinkthat heightens me a little more that
maybe there's something else going on.
And then again, I, I think that thisis the time where you ask family,
you know, while you're examining thepatient, what medicines they're on
and what medicines they've respondedwell to or poorly in the past.

(22:38):
I had a family recently that really askedme not to give Keppra because they said
the patient has a lot of psychiatricissues coming off of Keppra afterwards,
so I ended up going with fosphenytoininstead of Keppra after talking with
neurology, because it seemed like thatwas probably the best thing for the
patient, even though the loading timeon  fosphenytoin is significantly slower.

Sam (22:58):
Yeah.
And you can also ask about thingslike, you know, have they had multiple
seizures like this in the past?
And sometimes I find that to be kindof something that just reduces my
anxiety when the, parent says, ohyeah, you know, usually they have
these stacked 5, 6, 7 in a row over thecourse of a few hours, and I go okay.
Okay.
So now I know what we're dealing with,you know, oh, they're on five different

(23:20):
anti-epileptics and we're gonna runthe gamut of the meds with them,
but it's been difficult to control.
That's very, very helpfulinformation to elicit for sure.
In the physical exam sectionalso, you wanna note the response
to any medications you've given.
You know, sometimes we relyon our nursing colleagues.
We say, okay, go give them 10 of Midazolamright now and then I'll be right back.

(23:41):
And, you know, if the nurse comes upand says, Hey, great news, they've
stopped seizing, I have personallyhad these scenarios where it is
thought that they stopped seizing.
And then I walk in and Iopen their eyes and I go, eh,
their eyes are still deviated.
They're not as tense, butI'm gonna pick up their arms.
And there's still some increasedtone in these extremities, and this
seizure hasn't actually stopped.
They're just not overtly shaking.

(24:02):
So the subtleties matter whenit comes to this examination.
You don't have to pull out yourreflex hammer, but you do have to
go and pick up the arm or the legand check the tone, look at the eyes
and most of the time, I think you'llget your answer pretty quickly.

T.R. Eckler (24:14):
And I think like to your point too, I think this is something
where we're always kind of really highlysuspicious and the data backs this up.
Like I think 50% of patients thataren't coming back to normal, are
still in non convulsive status.
So we're chasing the right fearhere, like this is not something
where like, you know, one in ahundred or one in a thousand.
These patients are stillhaving some signs of seizures.

(24:36):
So like your desire to escalateand keep going and push further
is rightly, I think, justified.

Sam (24:41):
Yeah.
Yeah, great point.
Not a zebra.
It definitely occurs and it occurs a lot.
There is a good table on pagenine about laboratory testing.
So once you've gotten past the physicalexam and we're jumping into diagnostics,
everybody's getting a very broad setof labs, which includes the metabolic
profile but a finger stick glucose, ifit wasn't already done by EMS or they

(25:02):
didn't come in by EMS, that's somethingyou're gonna do first, right away.
A complete blood cell count looking forleukocytosis and signs of infection.
Typically seizures can evencause transient leukocytosis.
So just an elevated white blood cellcount by itself doesn't mean it's
infectious, but something to keep in mind.
The comprehensive metabolic profile,which most of time does not include your
ammonia, so if you're gonna get some liverfunctions, adding the ammonia is helpful.

(25:26):
Sometimes the ammonia is just high becauseof the anti-epileptics they're taking too.
'Cause that can affect liver functiondepending on which agent they're taking.
So

T.R. Eckler (25:34):
Also doesn't give you a magnesium level, so you
gotta add a magnesium on topif, if you're chasing that.

Sam (25:39):
Yeah, for sure.
Urine is helpful because it can bea source for infection, but also if
you're doing urine toxicity screensinstead of serum toxicity screens,
you need to know if they havethose metabolites in their urine.
Again, not a hundred percent.
There are a lot of things that'llgive you false positives, so make
sure you, you're aware of that.
Serum levels for medications andfor exposures, so toxicity, things

(26:00):
like Tylenol and alcohol and,

T.R. Eckler (26:03):
Lithium.

Sam (26:04):
Lithium.
Yes.
Yes, absolutely.

T.R. Eckler (26:06):
Great one.
I think in this day and age too,there's such a challenge of following
up with primary care and neurology.
I've started sending more and more seizuredrug levels, and I just had a patient
bounce back who was a seizure patientwho wasn't able to follow up, still
felt like she was gonna have a seizure,felt like she had prodromal stuff, and
I got to see that her Keppra level wastherapeutic, but she was still kind of

(26:27):
having a sense of breakthrough seizures.
So I got to kind of adjust.
I got to kind of help her get better,closer follow up, but I felt like
it answered the question of hercompliance, so I think it's gonna help
her get on a second line agent if shekinda continues to have symptoms or
adjust her medication where it is now.

Sam (26:41):
I like that.
I like that a lot.
Yeah, it kind of takes a non-complianceout of the picture and really kinda lends
validity to the fact that this person'sactually trying and has been compliant.
That's good.

T.R. Eckler (26:50):
They're send out tests and I think a lot of times we tend to brush
off send off tests in the ER, but I thinkthat this is gonna help these patients
get better care when they kind of continueto follow up even if they're just coming
back to the ER 'cause you can makebetter decisions if you have better data.

Sam (27:05):
Excellent point.
Lactate levels, prolactin levels.
Now these are sometimes measured10 to 20 minutes after a seizure
and have a sensitivity and aspecificity about 53% and 93%.
So it's not perfect.
Just because they don't have an elevatedprolactin level doesn't mean they
weren't having a legitimate seizure.

(27:25):
But if they do, again, it can help youin that differential, especially if
you're considering something like thepsychogenic, non-epileptic variety.
Creatinine kinase becauseof rhabdo, which can happen,
especially with prolonged seizures.
And since we're talking about statusepilepticus, if they're continually
seizing for a long period of time,something you need to be aware of.
They can develop the rhabdomyolysisand acute kidney injury.

(27:45):
Troponin is interesting actually, andit's not one that I think about initially
in my laboratory battery for statusepilepticus, but it does drive home
the point that if there is concern thatthey had syncope first and that they
maybe had multiple seizures insteadof the continuous seizure, maybe this
is cardiogenic, maybe they're havingsome kind of arrhythmia each time

(28:08):
that we see a seizure on the outside.
And the only point there wasthat if the troponin's elevated,
you need to repeat it and maybeconsider further cardiac testing.
So it's a good point to drive home.
Cultures if they're febrile,and then pregnancy test, if
they're within the age range.
That is a critical test to obtain becausethe treatment pathway takes a giant

(28:30):
left turn if the patient is pregnant.

T.R. Eckler (28:33):
And I think that sometimes blood tests take a long time.
So this is my annual reminderthat most rapid urine cartridges
in the United States are dualcertified for blood and urine.
So you can just take whole blood, putit on that cartridge, and it will give
you an answer as to whether the patientis pregnant in just a couple of minutes.
So if you've got questions and you'rereally worried, just have the lab

(28:53):
send you one of those cartridgesand you can know right away.

Sam (28:56):
There you go.
May have to do it yourself if thelab tech is not allowed to do it,
but doesn't mean you can't do it.
Alright, let's talk about imaging.
So you know, status epilepticus, I thinkmost people are going to get some kind
of imaging especially if they have anunusual change and this is not their norm.
It's hard to believe that itwill be the norm for anybody.
But the point driven, I think, by theAmerican College of Emergency Physicians

(29:18):
is that most of these patients aregonna get a CT scan without contrast.
That's what we haveavailable in our department.
And then at some point they'll goon to get MRI imaging, you know,
after neurology's gotten involved,to look for some of the more subtle
things that can cause abnormalities.
But just keep in mind, the non-contrastCT doesn't rule out everything bad.
So you may have to go chase it withother things especially if you're looking

(29:41):
for increased intracranial pressure.
Now if they're not having the generalizedtonic-clonic seizure, this is a good
opportunity to pull out your ultrasoundand do a quick ocular ultrasound and
look at their optic disc and get thatquick optic nerve measurement, and
that can give you a, measurement thatcan suggest increased intracranial
pressure as an etiology and is aquick, rapid bedside test to do.

(30:03):
So, something to think about.
And if you're worried about otheretiologies you can then get things like
CT venograms, MR venograms in patientswho are hypercoagulable or pregnant or
have a persistent headache, or if you dothe ultrasound and you see papilledema.
So all of those things are possibilities.
But by far, the initial studythat we're all obtaining is just

(30:25):
a non-contrast CT of the brain.
Then moving on to somethingthat may be necessary.
And that's the lumbar puncture.
So if you have an abnormal ultrasoundfinding and you are considering
increased intracranial pressure, thenthat is one way to measure it directly.
Obviously, again, very difficultto do while they're still seizing.
So this is kind of after you'veeither terminated the seizure or

(30:47):
intubated them and initiated a coma,and then now you're able to have
them be still for this procedure.
It's also very helpfulto look for infections.
It's helpful to look for pleocytosis,evidence for increased protein
and other things that can help youdown the differential diagnosis
for causes for status epilepticus.
So it's not just for pressureand not just for infection.

T.R. Eckler (31:09):
Yeah, I think more autoimmune, more neoplastic cases like,
I think that's more and more of whatwe're starting to see is that these
cases that we can't find a cause,the more we get into them, the more
finding it's those kinds of things.
And I think the more you can get anLP on those patients, and the earlier
you can get it, I think the more yieldyou're gonna get and the faster the
inpatient team's gonna get to the answer.

Sam (31:29):
And you don't even have to know what tests you need to order.
Just get the fluid andhave it sitting in the lab.
You're gonna look for infection, andthen they'll add on a bunch of you
know, antibodies and things that they'relooking for considering the differential

T.R. Eckler (31:39):
Fancy upstairs tests is what I call 'em.

Sam (31:43):
Nice.
And then there's the EEG.
So again, it's very, very helpfulto get neurology involved early.
If you have an EEG tech and theability to get these EEGs in the
emergency department, it's veryhelpful to get them contemporaneously
with all the other stuff.
It's exceedingly helpful in thedifferential diagnosis and to
determine if they're still seizing.

(32:04):
You know, the ESSEP trial thatthe authors mentioned was a
randomized controlled trial, 475patients in 58 different hospitals.
48%, so only half of the patients,actually had altered consciousness
following status epilepticus and continuedto have non convulsive seizures on EEG.
So, half of those still seizing, butwithout any external signs of continued

(32:27):
seizure, like you mentioned before.
And so this can be particularlychallenging and this is a great tool
for trying to detect that early.

T.R. Eckler (32:35):
This technology is just advancing.
I feel like we're gonna see more andmore interesting ways to like do seizure
monitoring on people as it just getsmore micro and easier to use, you know?

Sam (32:44):
Yeah, and typically the EEG testing we're doing in the ED is spot testing, or
it's kinda a one time 30 to 60 minutes andthen it's done, but these patients really
need continuous EEG monitoring, especiallyif they're intubated and going to the ICU.
And so that can be done withtraditional EEG equipment.
It can be done with video.
It can be done with some of the newerAI technology that is also monitoring

(33:05):
brainwaves and then alarming.
So lots of different options.
And there are even some smaller productsnow for emergency departments that don't
have EEG techs available where you cando a spot EEG with just two or three
electrodes and get a quick reading.
They're not as accurate.
They do have a lot of false positives,so, you know, understanding all of
that, the technology's getting better.

(33:26):
But hopefully if you don't haveEEG where you are, you've got
one of these devices you can atleast get an initial reading from.
All right, let's talk about treatment.
So there is, we touched on this alreadywith Midazolam, but there's a great
table on page 10, medications for statusepilepticus, which gives you first line,
second line, and third line agents.
The first line agents are alwaysgoing to be the benzodiazepines.

(33:49):
Rapid onset have very goodevidence for terminating seizures
even in status epilepticus.
And that's what you want to give first.
You do have IV and IM available toyou with Lorazepam and midazolam.
There are some parents with childrenwho seize at home who are still
using the rectal diazepam as well.
But Midazolam and Lorazepam bothhave actually better efficacy.

(34:11):
So if you have an IV or can give itIM, that's still the preferred route.

T.R. Eckler (34:16):
There's a new product called Valtoco that's basically nasal Valium,
and I find that that's replacing a lot ofthe rectal Valium that's out there now.
I also would note that I think that drugshortages are really affecting this.

Sam (34:28):
Mm.

T.R. Eckler (34:28):
Right now we don't have any access to Lorazepam.
So despite it being the first lineagent, it's not something that
we have readily available in theintravenous form in our hospital.
So you've gotta be ready to adjustto hospital supplies, drug shortages.
So I think that's why this table is sovaluable is because you need to be ready
to use what agents you have and then beready to escalate, not just to like one

(34:50):
of the things in the next group, butany of the things that are available,
depending on what you have and what thepatient actually responds to in the past.

Sam (34:56):
Yeah.
Yeah.
And on this topic, it's also importantto make sure you're giving the right
dose based on the person's weight.
So, you know, adult doses of lorazepamare maximum four milligrams per dose,
but it's 0.1 milligrams per kilogram.
If you're dosing midazolam especiallyif you're giving it IM in an adult,
it's 0.2 milligrams per kilogramwith a maximum of 10 milligrams.

(35:18):
So underdosing is a frequent problemthat results in recurrent seizures
and in continued status epilepticus.
So don't be afraid to givethe full dose and if they have
somnolence and respiratoryfailure, you deal with all that.
You have the tools towork with all of that.
But priority number one isterminate the seizure and make
sure you're giving the right dose.

T.R. Eckler (35:39):
Stopping a seizure, but arriving in intubation is a win
so long as their glucose is normal.
That's my feeling aboutstatus patients like this.

Sam (35:46):
That's perfect.
That is a perfect summary.
Second line agents includethings like levetiracetam,
valproate sodium, fosphenytoin,phenobarbital, and lacosamide.
So all of these medications are in thesecond line therapy arena, and you're
gonna give your benzos and you'reprobably gonna give your benzos again

(36:07):
before you reach for one of these things.
So it's like, give a dose ofbenzos, wait a minute or two, give
another dose of benzos, and thenreach for one of these agents.
And this is where it becomes helpfulto know what they're taking at home,
because it may or may not be effective.
If they haven't been on it for a while,you may have to give a loading dose.
Levetiracetam has always been my favoritejust because of the ease of dosing and

(36:27):
the loading and I think our neurologycolleagues quickly became fans of it as
well because of its ability to be loadedin people with renal failure and with
all kinds of other metabolic issues.
It's like just give the loading dose andwe'll worry about the next one later.
But there are others.
So keep in mind there are fourothers to choose from on the
list besides levetiracetam.

(36:48):
And like you mentioned before, just knowwhat you have in your pyxis, know what you
have in your pharmacy, and consider howlong it's gonna take to give it as well.

T.R. Eckler (36:56):
Levetiracetam for a hundred kilogram person, you can give it in
about nine minutes, if you're kind ofgoing at the max rate of about five mgs
per kilo per minute, but then if you'relooking at the other drugs on there,
it's gonna take significantly longer.
And I think that then adjusts, ifyou know you start that load, but the
patient starts seizing, you need to beready to move to your third line agents.

(37:16):
You know, maybe think about a doseof ketamine, or you're going to full
on intubation and the other drugs.
But I think you need to know how long it'sgonna take to get that medicine into the
patient, and then be ready with how yourplan responds according to what you've
got available and what you're gonna use.

Sam (37:30):
And keep in mind, the maximum dose is probably way higher
than anything you've ever given.
You know, levetiracetam's a greatone, max dose four and a half grams.
Can't say I've ever dosed anybody withthat much but your neurology colleague
may ask you to do so for somebodyheaded to the ICU with continued non
convulsive status on EEG, you're gonnakeep pushing that higher and higher.

(37:51):
So just be aware that the max dose ismuch higher than the routine dose we give.
All right.
And then third line agents.
So this is the person who's now aboutto be intubated and put on a ventilator.
And we're looking forcontinuous infusions, right?
So Midazolam still in this list,right, has shown good efficacy.
There is good published data formidazolam versus propofol, and they're

(38:14):
about equal for continuous infusion.
Now, whether or not you havemidazolam available and that much
available is another question, butjust know that can be a method for
controlling continuous seizures.
Propofol certainly always one of myfavorites, but comes with the propofol
infusion syndrome as a possible sideeffects and lots of derangements and

(38:35):
increased morbidity and mortality.
So uh, your colleagues in theICU may rapidly change them to
something else, and that's okay.
Pentobarbital is something I havepersonally never given, but may
be available in your pharmacy.
Thiopental is also somethingI've never had to give, but may
be available in your pharmacy.
And lastly, ketamine.

(38:56):
So ketamine, interestingly, a littleasterisk there, was recommended by the
authors as something you might try beforeyou reach for a continuous infusion
and intubate somebody as a single dosebecause there is a growing number of case
reports of people who have terminatedseizures with a dose of ketamine.

(39:17):
Not as a continuous infusion,but just a dose of ketamine
before progressing to intubation.
And you might be able to keepsomebody off a ventilator.

T.R. Eckler (39:25):
I think especially as you're getting ready to
start infusion, it takes time.
I think you've got that moment therewhere if they're still seizing or
showing you signs of non convulsivestatus where they're not coming around.
I think that there's room for thatdose of ketamine, while you're
getting set up for everything else.
I also think to your point, I reachmore for midazolam in children and
I reach more for propofol in adults.

(39:46):
But I think it depends on kindof the patient's history, what
their blood pressure looks like.
I think there's a lot of factors thatgo into this and I think that all of
those things are now always part of myevolving approach to these patients.

Sam (39:57):
And if you're wondering, you know, about the clinical efficacy for
each of these medications, especiallylike second and third line agents, the
authors did a good job of saying, yes,there is published data for all of these
and the efficacy is about the same.
So you know, levetiracetam doesn'twork necessarily any better than
fosphenytoin, and doesn't necessarilywork any better than valproate
and propofol doesn't necessarilywork any better than midazolam.

(40:19):
It's more what you have andwhat you can get quickly.
Okay.
And then these are the patients whoare going to the ICU and considered
super refractory status epilepticus.
So I think that's gonna be the highestcategory where they just continue
to seize no matter what you do.
And I think that at this point,if you haven't already gotten your
neurology colleagues involved,it's going to be whatever agents

(40:40):
they prefer on top of whatevercontinuous infusion you've provided.

T.R. Eckler (40:44):
To the final boss of the NORSE seizure battle
game that you're playing.
This is like the tough boss thatyou've gotta use all your weapons on.

Sam (40:52):
That's right.
The big boss at the end of the video game

T.R. Eckler (40:54):
The big boss at the end.

Sam (40:56):
And then some special populations, right?
So there are going to be some caseswhich are handled differently.
Pregnancy is certainly one of them.
So if your patient is pregnantand presenting with continuous
seizures or status epilepticus, theneclampsia needs to be at the top
of the list, and the first agentyou're reaching for is magnesium.

(41:16):
And that is a giant whopping dose of fourto six grams IV over 15 to 20 minutes.
So it's a very rapid infusion ofmagnesium, followed by a continuous
infusion of one to two grams per hour.
And then you're getting your OB colleaguesinvolved and kind of discussing maybe
delivering of the baby at this point.
So that's a very, very different pathwaythat you need to identify immediately

(41:40):
before you are giving other substances.
Now you can still give lorazepam,you can still give fosphenytoin,
you can still give levetiracetam.
Some of them don't have the greatestside effect profile in pregnancy.
But if they get the mag and theycontinue to seize , you're not out of
medication treatment at that point, youcan still give these other agents in

(42:00):
consultation with your neurologist andyour OB because the longer the mother
is seizing, the longer her brain is atrisk and the longer the fetus is at risk.
So you're saving bothlives in this scenario.

T.R. Eckler (42:12):
You did put a little caution on fosphenytoin and valproic acid . So
it seems like levetiracetam, which you'reso much better at saying than I am, is
more of the kind of recommended third lineafter your, magnesium and your benzos.
But as I think you said, I thinkyou give those three things while
you're punching the number for OBGYNand getting them to the bedside.
'Cause delivery is really the thingthat's gonna save this duo here.

Sam (42:35):
Yeah.
And you know, in pregnancy, it's notjust eclampsia, but it's things like
posterior reversible encephalopathysyndrome, reversible cerebral
vasoconstriction syndrome and corticalvenous thrombosis, all of these things can
cause seizures in the pregnant patient.
So the differential is different and itis treated differently in most cases.

(42:55):
Just don't forget the mag andthe mag and the mag because
that's the treatment of choice.
There is substance induced status
epilepticus, so somewhere betweennine and 10% of status epilepticus
cases are substance induced.
And these are things like antidepressants,stimulants, antihistamines,

(43:15):
tramadol, isoniazid, and theycan have some specific therapies.
So if you know that they're usingisoniazid and they're toxic from it, then
pyridoxine is the treatment of choice.
Phenytoin interestingly,not as highly recommended in
drug-induced status epilepticus.
Doesn't tend to do as well.
But your other choices are pretty good.
And your, you know, your first drug?

(43:35):
Well, my first drug levetiracetamis the one that seems to
work okay in these patients.
So just know that there's a significantnumber of patients and drug toxicity
is definitely in the differential.

T.R. Eckler (43:46):
Your catch for the isoniazid patient is a tuberculosis patient that
tried to kill themselves and took toomuch of their tuberculosis medicine.
And I think the classic teaching on thisis that if you need B6 to try to stop
these people's seizures, you need allthe B6 in your hospital and all the B6
in a bunch of surrounding hospitals.
So once you've made this diagnosis, it'salso one where you need to make that

(44:07):
next step to talk to your pharmacy andsay, Hey, we're gonna need a lot of B6.
You know, this is what I've got.
Figure out how much we'regonna need and then figure out
where we're gonna get it from.
And let me know.

Sam (44:15):
Yeah, and you're gonna need some isolation.

T.R. Eckler (44:18):
Well, it depends.
If it's not really active TB, youjust, you can just fix the seizures.
But, we'll, we'll get to that part.
I'm sure they came in with full PPE.
Well contained.
Everything taken care of.

Sam (44:29):
And then there was a great section there on pediatric patients,
which actually I'm not going to diveinto, but I will encourage you to
go back a couple of months on thispodcast and listen to the episode we
did on pediatric status epilepticus.
It is a little different but overallI think the management points
were, were very, very similar.
You stop the seizure, stop itearly and make sure you're aware

(44:50):
of what medications you have andwhat exposures the patient has had.

T.R. Eckler (44:54):
Here's my annual plug for the wonderful PD stat app, so that if you have
a kid that's sick with anything, you canuse the PD stat app to base your doses for
their medications on their Broselow Tape,or their age or their weight, whatever
you've got, the most accurate measurementyou have for their age and size.
Then that will give you every drugyou need and everything you need
to resuscitate them right there.
It makes the cognitive load decreasedramatically so you can just focus

(45:17):
on getting that little buggerhealthy and back to normal again.

Sam (45:20):
Yeah.
Before we end, I wanna put in a quick plugfor the risk management pitfall section
in every single one of these issues.
They're fantastic.
We're gonna go through a coupletoday for the status epilepticus.
The first one, the patient isn'thaving any abnormal movements,
so he's not seizing anymore.
I think we drove thatpoint home pretty well.
That non convulsive status epilepticus isa thing and you should be very suspicious.

T.R. Eckler (45:43):
Turn.
Turn that on its head a little bit.
If the patient isn't moving,you should be a little worried.
They should start moving.

Sam (45:49):
Yeah,

T.R. Eckler (45:50):
Movement, good.
Too much movement, bad.
No movement, also bad.

Sam (45:54):
Also bad.
That's right, that's right.
There is a sweet spotsomewhere in the middle

T.R. Eckler (45:57):
Yes.

Sam (45:58):
Number two, we gave two milligrams of lorazepam so the seizures should stop.
The point here being that it's nota standard dose, it's a weight-based
dose, and you wanna give the correctamount based on the patient's weight,
which could be up to four milligrams.
And repeat that once with a maximumdose of eight milligrams before
you go on to your next agent.
So if you gave them two and it didn'twork and you gave them two more,

(46:20):
you're only halfway there beforeyou should be giving anything else.
So make sure you get the right amount.
The point of care EEG showed noseizures, so we didn't need formal EEG
monitoring, and that's just a reminderthat this particular product is good
to have but doesn't yet have thesensitivity and specificity needed to
completely exclude continued seizures.

(46:42):
So you still need a dedicatedEEG for the non convulsive cases.

T.R. Eckler (46:47):
So you've just given them a ton of drugs to tamp down
their ability to have a seizure.
So you need to then watch them as thosedrugs fade away to see what develops.
And that's what they'regetting admitted for.

Sam (46:57):
Yep.
And if you can't do that atyour facility, that's okay.
You gotta send them somewherewhere they can Right.
Transfer them.
The patient has a history of epilepsy, sothe seizure must be due to non-adherence.
No further workup is required.
I think your example of the levetiracetamlevel you did on that patient,
it was a, was a great one, right?
So she was compliant andyet still having seizures.

(47:17):
It happens.
Something to keep in mind.

T.R. Eckler (47:19):
I had an alcoholic once in rural Colorado that was known to
go into withdrawal seizures, and Iwas used to giving him a dose or two
and he would stop and we'd be fine.
And I, one time I just couldn't get him tostop and I had to intubate him and I felt
like I just had not managed it correctly.
And then I took him to CT andhe had a giant head bleed.

Sam (47:34):
Hmm.

T.R. Eckler (47:36):
That's, it's one of those things where, if the patient has a
history of seizures and you're notgetting them to come around , it's
'cause there's something else there.
So keep working 'em up,keep working the problem.

Sam (47:44):
Great case.
Great case.
The patient has renal failure, so I shouldreduce the loading dose of levetiracetam.
Again, that loading doseis the same upfront.
Now your follow-up doses may bedifferent and the schedule may be
different, but the load is the same.
We successfully treated theseizures so the patient does
not need a higher level of care.
Interesting point here that if a patientis no longer seizing and they don't meet

(48:07):
the critical care unit requirements youstill need admission to an inpatient
neurology service or a place where that'savailable to get the rest of the workup.
And so terminating the seizures, great.
That gets you most of the way there, butthen you gotta figure out why it happened.

T.R. Eckler (48:22):
Again, these are patients with status epilepticus.
It's not just patients with justseizures that come back to baseline.
The patients with status whoaren't returning their baseline,
who've had multiple seizuresrequired multiple medications.
There needs to be a higher threshold forthese patients than just your usual had
one seizure and now is normal patient.

Sam (48:39):
The patient's seizures stopped after I administered benzodiazepines,
so they don't need any more medication.
And the point here being that greatyou have terminated their seizure.
But that medication is verytemporary, very short acting.
And they need one of those second lineagents to provide consistent control and
not allow any more breakthrough seizures.

(49:00):
So just terminating it is not enough.
And lastly, the patient saturationsare in the low nineties, so
I'll give a lower dose ofbenzodiazepines to protect the airway.
And this really just drives the pointof you're gonna stop the seizure first
and deal with the respiratory depressionsome other way by controlling the airway.
Don't worry about respiratory suppressionbecause if it happens, you're gonna

(49:23):
need to intubate this patient anyway.
Stop the seizure, don't let it continue.

T.R. Eckler (49:28):
And their receptors are downregulated, so you need
more benzo to break through that.
So I liked their argument.
I thought it was a good one.

Sam (49:36):
Yep.
More benzos, more quickly,as fast as you can.
And as always, the lastpage has a clinical pathway.
So it includes the medications,the dosing, the first, the second
line, the third line, when togive 'em, do the seizures persist,
how to give 'em, et cetera.
It's a great little pathway to have.
So if you don't want just a table of medsand you want a step-by-step progression,
it's a great one to have in your backpocket for how to treat these patients.

(49:59):
They are very anxiety provoking patientsbecause you want to stop the seizure and
you don't kind of get to relax and pauseuntil you stopped the overt seizure.
So having a clinical pathway in yourback pocket is exceptionally helpful.
And offloads some of thatbrain activity of your own.
All right, ladies and gentlemen,that's it for the September 2025 issue

(50:21):
of Emergency Medicine Practice onstatus epilepticus in adult patients.
Thanks again to the authors.
Fantastic article, great summaries,great tables, and an excellent pathway.
And as always, I'm Sam Ashoo.

T.R. Eckler (50:34):
TR Eckler, good luck with those super Vikings.

Sam (50:37):
The Norse.
The Norse.
My nemesis.
All right, thanks everybody.
See you next time.
And that's a wrap forthis month's episode.
I hope you found iteducational and informative.
Don't forget to go to ebmedicine.netto read the article and claim your CME.
And of course, check out all threeof the journals and the multitude of
resources available to you, both foremergency medicine, pediatric emergency

(51:01):
medicine, and evidence based urgent care.
Until next time, everyone be safe.