Status Epilepticus Medical Slides

Use a timeline visual: 0-5 min (stabilize, obtain access, labs), 5-20 min (benzodiazepines: IV lorazepam 0.1 mg/kg or IM midazolam 10 mg per RAMPART), 20-40 min (second-line: fosphenytoin 20 mg PE/kg, valproate 40 mg/kg, or levetiracetam 60 mg/kg — all equivalent per ESETT), 40-60 min (refractory SE: intubation, continuous infusion). Emphasize that treatment delay is the strongest predictor of treatment failure.

The Established Status Epilepticus Treatment Trial (2019) randomized 384 patients with benzodiazepine-refractory SE to IV fosphenytoin, valproate, or levetiracetam. Seizure cessation rates were equivalent (~45-50% for each). This resolved decades of debate and allows selection based on patient factors: avoid fosphenytoin in cardiac disease, valproate in liver disease or pregnancy, and levetiracetam if behavioral side effects are a concern.

Emphasize that NCSE accounts for up to 20-30% of ICU patients with altered mental status and requires continuous EEG monitoring for diagnosis. Present the ACNS criteria for electrographic seizures and the clinical spectrum from subtle behavioral changes to coma. Teach the "trial of benzodiazepines" diagnostic approach: clinical and EEG improvement after 1 mg lorazepam supports the diagnosis. NCSE carries significant morbidity from diagnostic delay averaging 24-48 hours.