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tablished A large-bore intravenous line is inserted; blood is drawn for glucose, blood urea nitrogen, electrolytes, and a metabolic and drug screen A normal saline infusion is begun and a bolus of glucose is given (with thiamine if malnutrition and alcoholism are factors) To rapidly suppress the seizures, diazepam is given intravenously at a rate of about 2 mg/min until the seizures stop or a total of 20 mg has been given Or lorazepam, 01 mg/kg given by intravenous push at a rate not to exceed 2 mg/min, may be administered, being marginally more effective than diazepam because lorazepam putatively has a longer duration of action in the CNS (see Tables 16-2 and 16-9) Immediately thereafter, a loading dose (15 to 18 mg/kg) of phenytoin is administered by vein at a rate of less than 50 mg/min More rapid administration risks hypotension and heart block; it is therefore recommended that the blood pressure and electrocardiogram be monitored during the infusion Phenytoin must be given through a freely running line with normal saline (it precipitates in other uids) and should not be injected intramuscularly A large study by Treiman and colleagues has demonstrated the superiority of using lorazepam instead of phenytoin as the rst drug to control status, but this is not surprising considering the longer latency of action of phenytoin Alldredge and colleagues have shown that diazepines can even be administered by paramedical workers with good effect in status epilepticus, terminating the seizures in about half of these patients Nonetheless, a long-acting anticonvulsant such as phenytoin is given immediately after diazepam has controlled the initial seizures An alternative is the water-soluble drug fosphenytoin, which is administered in the same doses as phenytoin but can be injected at twice the maximum rate Moreover, it can be given intramuscularly in cases where venous access is dif cult However, the delay in hepatic conversion of fosphenytoin to active phenytoin makes the latency of clinical effect approximately the same for both drugs In an epileptic patient known to be taking anticonvulsants chronically but in whom the serum level of drug is unknown, it is probably best to administer the full recommended dose of phenytoin or fosphenytoin If it can be established that the serum phenytoin is above 10 mg/mL, a lower loading dose is advisable If seizures continue, an additional 5 mg/kg is indicated If this fails to suppress the seizures and status has persisted for 20 to 30 min, an endotracheal tube should be inserted and O2 administered Several approaches have been suggested to control status that persists after these efforts The conventional and still dependable one is infusion of either thiopental, starting with 5 mg/kg, or phenobarbital, at a rate of 100 mg/min until the seizures stop or a total dose of 20 mg/kg is reached In our experience, a long period of stupor must be anticipated after seizure control is obtained, but some epileptologists still prefer this as the initial treatment Hypotension often limits the continued use of the barbiturates, but Parviainen and colleagues were able to manage this problem by uid infusions, dopamine, and neosynephrine (we tend to depend on neosynephrine) Alternatively, at this stage, we have resorted to the approach of Kumar and Bleck, of giving high doses of midazolam (02 mg/kg loading dose followed by an infusion of 01 to 04 mg/kg/h as determined by clinical and EEG monitoring) If seizures continue, the dose can be raised as blood pressure permits We have had occasion to use in excess of 20 mg/h because of a diminishing effect over days This regimen of midazolam and phenytoin may be maintained for several days without major ill effect in previously healthy patients Propofol given in a bolus of.

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