Seizures

STATUS EPILEPTICUS — MEDICATIONS & DOSAGES

(GENERIC / BRAND)

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🟥 FIRST LINE (5–10 min)

Lorazepam (Ativan)

• 4 mg IV push over 2 min
• If seizures persist after 5 min → repeat 4 mg IV x1

If NO IV access

• Diazepam (Valium) — 20 mg PR
• Midazolam (Versed) — 10 mg IN / buccal / IM

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🟧 SECOND LINE (10–30 min)

(Load one or more; may combine)

Valproic Acid (Depakote)

• 40 mg/kg IV
• Max rate: 6 mg/kg/min

Levetiracetam (Keppra)

• 20 mg/kg IV
• Max rate: 100 mg/min

Phenobarbital (Luminal)

• 20 mg/kg IV
• Max rate: 50–75 mg/min

Fosphenytoin (Cerebyx)

• 20 mg PE/kg IV
• Max rate: 150 mg PE/min
• If inadequate response:
  • Additional 10 mg PE/kg IV

Phenytoin (Dilantin)

• 20 mg/kg IV
• Max rate: 25–50 mg/min
• Additional 10 mg/kg IV if needed

Lacosamide (Vimpat)

• 400 mg IV over 5 minutes
• EKG required pre/post

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🔎 Drug Levels After Load

Medication	Level Timing
Phenytoin (Dilantin)	1 hr
Valproate (Depakote)	1 hr
Phenobarbital (Luminal)	1 hr
Fosphenytoin (Cerebyx)	2 hrs

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🟥 THIRD LINE (30–60 min)

Refractory Status Epilepticus
➡️ INTUBATE + Continuous EEG

Midazolam (Versed) — preferred if hypotensive

• Load: 0.2 mg/kg IV
• Repeat q5 min until seizure stops
  • Max total load: 2 mg/kg
• Maintenance: 0.1–2 mg/kg/hr

Propofol (Diprivan)

• Load: 2 mg/kg IV
• Repeat q5 min until seizure stops
  • Max total load: 10 mg/kg
• Maintenance: 1–10 mg/kg/hr
  • <5 mg/kg/hr if >48 hrs

🎯 Goal: seizure cessation or burst suppression

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🟩 MAINTENANCE THERAPY & TARGET LEVELS

Generic (Brand)	Daily Dose	Target Level
Valproic Acid (Depakote)	30–60 mg/kg/day (BID)	70–120 µg/mL
Levetiracetam (Keppra)	2–4 g/day (BID)	25–60 mg/L
Phenobarbital (Luminal)	1–4 mg/kg/day (BID)	20–50 mg/mL
Fosphenytoin (Cerebyx)	5–7 mg PE/kg/day (TID)	15–25 µg/mL (total)
Phenytoin (Dilantin)	5–7 mg/kg/day (TID)	Free 1.5–2.5 µg/mL
Lacosamide (Vimpat)	400–600 mg/day (BID)	No established level

⚠️ Correct total phenytoin for albumin/renal function; check free level if needed.

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🟥 FOURTH LINE (>72 hrs)

Super-Refractory Status Epilepticus

Magnesium Sulfate

• Bolus 4 g IV
• Infusion 2–6 g/hr

Ketamine (Ketalar)

• Load: 1.5 mg/kg IV
• Repeat q5 min until seizures stop
  • Max load: 4.5 mg/kg
• Maintenance: 1.2–7.5 mg/kg/hr

Pentobarbital (Nembutal)

• Load: 5 mg/kg IV (max rate 50 mg/min)
• Repeat q5 min until seizures stop
  • Max load: 15 mg/kg
• Maintenance: 1–10 mg/kg/hr

Pyridoxine (Vitamin B6)

• 200 mg IV daily

Immunotherapy (if autoimmune suspected)

• Methylprednisolone (Solu-Medrol) — 1 g IV daily x 3–5 days
• IVIG (various brands) — 0.4 g/kg/day x 5 days
• Plasma exchange

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🧠 High-Yield Pearls

• Lorazepam (Ativan) first — always
• Load early, load fully
• Refractory = intubate + EEG
• Midazolam (Versed) if hypotensive
• Propofol (Diprivan) → watch for PRIS
• Ketamine (Ketalar) useful late (NMDA blockade)