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

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