Proposed Algorithm for Convulsive Status Epilepticus
`From 'Treatment of Convulsive Status Epilepticus in Children and Adults," Epilepsy Currents 16.1 -Jan/Feb 2016
`
`Time Line
`
`Interventions for emergency department, in-patient setting,
`or prehospital setting with trained paramedics
`
`0-5 Minutes
`Stabilization
`Phase
`
`1. Stabilize patient (airway, breathing, circulation, disability - neurologic exam)
`2. Time seizure from its onset, monitor vital signs
`3. Assess oxygenation, give oxygen via nasal cannula/mask, consider intubation if respiratory assistance
`needed
`4. Initiate ECG monitoring
`5. Collect finger stick blood glucose. If glucose < 60 mg/di then
`Adults: 100 mg thiamine IV then 50 ml D50W IV
`Children > 2 years: 2 ml/kg D25W IV Children < 2 years: 4 ml/kg D12.5W IV
`6. Attempt IV access and collect electrolytes, hematology, toxicology screen, (if appropriate) anticonvulsant
`drug levels
`
`Does Seizure
`Continue?
`
`5-20 Minutes
`Initial Therapy
`Phase
`
`A benzodiazepine is the initial therapy of choice (Level A):
`Choose one of the following 3 equivalent first line options with dosing and frequency:
`• Intramuscular midazolam (10 mg for > 40 kg, 5 mg for 13-40 kg, single dose,
`Level A) OR
`• Intravenous lorazepam (0.1 mg/kg/dose, max: 4 mg/dose, may repeat dose
`once, Level A) OR
`• Intravenous diazepam (0.15-0.2 mg/kg/dose, max: 10 mg/dose, may repeat dose
`once, Level A)
`If none of the 3 options above are available, choose one of the following:
`• Intravenous phenobarbital (15 mg/kg/dose, single dose, Level A) OR
`• Rectal diazepam (0.2-0.5 mg/kg, max: 20 mg/dose, single dose, Level B) OR
`• Intranasal midazolam (Level B), buccal midazolam (Level B)
`
`If patient at baseline,
`then symptomatic
`medical care
`
`Does Seizure
`Continue?
`
`20-40 Minutes
`Second Therapy
`Phase
`
`There is no evidence based preferred second therapy of choice (Level U):
`Choose one of the following second line options and give as a single dose
`• Intravenous fosphenytoin (20 mg PE/kg, max: 1500 mg PE/dose, single dose,
`Level U) OR
`• Intravenous valproic acid (40 mg/kg, max: 3000 mg/dose, single dose,
`Level B) OR
`• Intravenous levetiracetam (60 mg/kg, max: 4500 mg/dose, single dose, Level U)
`If none of the options above are available, choose one of the following (if not given
`already)
`• Intravenous phenobarbital (15 mg/kg, single dose, Level B)
`
`If patient at baseline,
`then symptomatic
`medical care
`
`Does Seizure
`Continue?
`
`40-60 Minutes
`Third Therapy
`Phase
`
`There is no clear evidence to guide therapy in this phase (Level U):
`Choices include: repeat second line therapy or anesthetic doses of either thiopental,
`midazolam, pentobarbital, or propofol (all with continuous EEG monitoring)
`
`If patient at baseline,
`then symptomatic
`medical care
`
`AMERICAN
`EPILEPSY
`SOCIETY
`
`Disclaimer: This clinical algorithm/guideline is designed to assist clinicians by providing an analytic framework for evaluating and treating
`patients with status epilepticus. It is not intended to establish a community standard of care, replace a clinician's medical judgment, or
`establish a protocol for all patients. The clinical conditions contemplated by this algorithm/guideline will not fit or work with all patients.
`ARGENTUM Exhibit 1067
`Approaches not covered in this algorithm/guideline may be appropriate.
` Argentum Pharmaceuticals LLC v. Research Corporation Technologies, Inc.
`2016 © Epilepsy Currents
`IPR2016-00204
`
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