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Treatment Approach

• Patients must be evaluated promptly and appropriate therapy instituted without delay.
  • General critical care supportive measures (e.g., airway, breathing, circulation)
  • Anticonvulsant therapy (see below)
• Consultation with a neurologist and critical care physician is advised.
  
  

Specific Treatments

Treatment protocol: General measures

• Assess carefully for evidence of respiratory or cardiovascular insufficiency.
  • With careful monitoring and standard airway protection, patients usually do not require intubation (if intubation is necessary, use short-acting paralytics).
• Establish intravenous access and administer:
  • 50% dextrose in water 50 mL
  • Thiamine 100 mg
  • Naloxone 0.4 mg
• Perform a brief medical and neurologic examination.
• Treat hyperthermia.
• Send samples for laboratory studies aimed at identifying metabolic abnormalities.

Treatment protocol: Anticonvulsant therapy

• Lorazepam (0.1 mg/kg IV at 2 mg/min)
  • Additional emergency drug therapy may not be required if seizures stop and the cause of SE is rapidly corrected.
• If seizures continue
  • Phenytoin (20 mg/kg IV at 50 mg/min) or fosphenytoin (20 mg/kg phenytoin sodium equivalents [PE] IV at 150 mg/min)
  • Monitor blood pressure; electrocardiogram; and, if possible, EEG during infusion.
  • Side effects: Phenytoin can cause precipitous fall in blood pressure if given too quickly, especially in elderly patients.
  • Precautions: Do not administer phenytoin with 5% dextrose in water as phenytoin precipitates at low pH. This is not a problem with fosphenytoin.
  • If seizures are not controlled, a repeat bolus of phenytoin (5–10 mg/kg) or fosphenytoin (5–10 mg/kg) may be given.
• If seizures continue
  • May add phenobarbital (20 mg/kg IV at 50–75 mg/min)
  • If lorazepam and phenytoin are ineffective in terminating SE, many physicians now bypass use of phenobarbital and proceed to anesthesia with midazolam or propofol, especially if patient displays severe systemic disturbances or has had seizures for longer than 60 minutes.
• If seizures continue
  • Anesthesia with midazolam, propofol, or pentobarbital

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