therapy whatever the seizure type or cause, and lorazepam, if available, is often the recommended initial drug. Most reviews recommend doses in adults of 4–8 mg administered intravenously no faster than 2 mg/min. The possibility that the seizures are precipitated by an acute medical condition should be kept in mind and subsequently investigated.
Recommendations for second‐line drug lack strong evidence and most reviews and guidelines recommend one of several drugs including phenytoin or fosphenytoin, valproate, or levetiracetam [55–59]. The recently completed ESETT trial for benzodiazepine refractory status epilepticus suggested that these drugs were of equivalent efficacy [60]. While these agents are not generally available in typical EMS environments, they may be found in critical care transport situations and EMS physician response teams. There is a trend in recent guidelines to deemphasize barbiturates in favor of levetiracetam, fosphenytoin, or valproate.
Refractory status epilepticus may be defined as generalized seizures that persist through administration of optimal benzodiazepines and a second‐line drug. There are no prospective, randomized trials to guide third‐line therapy. Anecdotal reports and recommendations list a variety of other agents, including high‐dose phenytoin [57], lidocaine [61–64], etomidate [65], ketamine [66, 67], midazolam [68, 69], propofol [69–73], and valproic acid [74–76]. There is a trend in the literature to recommend propofol for refractory generalized convulsive status epilepticus that fails to respond to optimal benzodiazepine and a second‐line drug administration. Definitive airway management and blood pressure support will be needed with the use of many of these agents.
Conclusion
Seizures are one of the most common conditions resulting in EMS activation. In many cases, the patient is recovering consciousness at the time of EMS arrival, and little if any care is needed. However, generalized convulsive status epilepticus represents an emergency with early interventions potentially limiting morbidity. After brief diagnostic intervention to confirm seizures, prompt treatment of persistent or recurrent generalized convulsions with benzodiazepines is indicated. A variety of treatment options is available for route of administration and drug choices. Retrospective review and commentary urge not delaying anticonvulsant administration in cases of generalized convulsive status epilepticus [77, 78]. Persistent convulsions will require additional ALS interventions.
References
1 1 Huff JS, Morris DL, Kothari RU, Gibbs MA, Emergency Medicine Seizure Study Group. Emergency department management of patients with seizures: a multicenter study. Acad Emerg Med. 2001; 8:622–8.
2 2 Richard J, Osmond MH, Nesbitt L, Stiell IG. Management and outcomes of pediatric patients transported by emergency medical services in a Canadian prehospital system. CJEM. 2006; 8:6–12.
3 3 Brokaw J, Olson L, Fullerton L, Tandberg D, Skiar D. Repeated ambulance use by patients with acute alcohol intoxication, seizure disorder, and respiratory illness. Am J Emerg Med. 1998; 16:141–4.
4 4 Fountain NB, Lothman EW. Pathophysiology of status epilepticus. J Clin Neurophysiol. 1995; 12:326–42.
5 5 Kapur J, Macdonald RL. Rapid seizure‐induced reduction of benzo‐diazepine and Zn2+ sensitivity of hippocampal dentate granule cell GABAA receptors. J Neurosci. 1997; 17:7532–40.
6 6 Goodkin HP, Yeh JL, Kapur J. Status epilepticus increases the intracellular accumulation of GABAA receptors. J Neurosci. 2005; 25:5511–20.
7 7 Lin JT, Ziegler DK, Lai CW, Bayer W. Convulsive syncope in blood donors. Ann Neurol. 1982; 11:525–8.
8 8 McCrory PR, Berkovic SF. Concussive convulsions. Incidence in sport and treatment recommendations. Sports Med. 1998; 25:131–6.
9 9 Perron AD, Brady WJ, Huff JS. Concussive convulsions: emergency department assessment and management of a frequently misunderstood entity. Acad Emerg Med. 2001; 8:296–8.
10 10 Huff JS. Stroke mimics and chameleons. Emerg Med Clin North Am. 2002; 20:583–95.
11 11 Hand PJ, Kwan J, Lindley RI, Dennis MS, Wardlaw JM. Distinguishing between stroke and mimic at the bedside: the brain attack study. Stroke. 2006; 37:769–75.
12 12 Haines SJ. Decerebrate posturing misinterpreted as seizure activity. Am J Emerg Med. 1988; 6:173–7.
13 13 Huff JS, Perron AD. Onset seizures independently predict poor outcome after subarachnoid hemorrhage. Neurology 2001; 56:1423–4.
14 14 Jagoda A, Riggio S. Psychogenic convulsive seizures. Am J Emerg Med. 1993; 11:626–32.
15 15 Leis AA, Ross MA, Summers AK. Psychogenic seizures: ictal characteristics and diagnostic pitfalls. Neurology. 1992; 42:95–9.
16 16 Mosewich RK, So EL. A clinical approach to the classification of seizures and epileptic syndromes. Mayo Clin Proc. 1996; 71:405–14.
17 17 Fisher RS, Cross JH, French JA, et al. Operational classification of seizure types by the International League Against Epilepsy: position paper of the ILAE commission for classification and terminology. Epilepsia. 2017; 58:522–30.
18 18 Kaplan PW. Nonconvulsive status epilepticus in the emergency room. Epilepsia. 1996; 37:643–50.
19 19 McKeon A, Frye MA, Delanty N. The alcohol withdrawal syndrome. J Neurol Neurosurg Psychiatry. 2008; 79:854–62.
20 20 Rathlev NK, D’Onofrio G, Fish SS, et al. The lack of efficacy of phenytoin in the prevention of recurrent alcohol‐related seizures. Ann Emerg Med. 1994; 23:513–18.
21 21 D’Onofrio G, Rathlev NK, Ulrich AS, Fish SS, Freedland ES. Lorazepam for the prevention of recurrent seizures related to alcohol. N Engl J Med. 1999; 340:915–19.
22 22 Alldredge BK, Lowenstein DH. Status epilepticus related to alcohol abuse. Epilepsia. 1993; 34:1033–7.
23 23 Olson KR, Kearney TE, Dyer JE, Benowitz NL, Blanc PD. Seizures associated with poisoning and drug overdose. Am J Emerg Med. 1993; 11:565–8.
24 24 Wills B, Erickson T. Drug‐ and toxin‐associated seizures. Med Clin North Am. 2005; 89:1297–321.
25 25 Wason S, Lacouture PG, Lovejoy FH Jr. Single high‐dose pyridoxine treatment for isoniazid overdose. JAMA. 1981; 246:1102–4.
26 26 Waruiru C, Appleton R. Febrile seizures: an update. Arch Dis Child. 2004; 89:751–6.
27 27 Allen JE, Ferrie CD, Livingston JH, Feltbower RG. Recovery of consciousness after epileptic seizures in children. Arch Dis Child. 2007; 92:39–42.
28 28 Treiman DM, Meyers PD, Walton NY, et al. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group. N Engl J Med. 1998; 339:792–8.
29 29 Treiman DM. Treatment of convulsive status epilepticus. Int Rev Neurobiol. 2007; 81:273–85.
30 30 Lowenstein DH, Bleck T, MacDonald RL. It’s time to revise the definition of status epilepticus. Epilepsia. 1999; 40:120–2.
31 31 Benbadis SR, Wolgamuth BR, Goren H, Brener S, Fouad‐Tarazi F. Value of tongue biting in the diagnosis of seizures. Arch Intern Med. 1995; 155:2346–9.
32 32 Lowenstein DH, Alldredge BK, Allen F, et al. The prehospital treatment of status epilepticus (PHTSE) study: design and methodology. Control Clin Trials. 2001; 22:290–309.
33 33
