Refractory status epilepticus

Status epilepticus is a well-recognized medical emergency that must be treated urgently to prevent permanent neuronal injury, prolonged unconsciousness, and even mortality. There is a high level of evidence that first-line treatment with benzodiazepines is indicated over other treatments based on a seminal double-blind randomized controlled trial of then-common treatments.¹ Second-line treatment is typically with IV antiepileptic drugs (AEDs), and while any drug might be used, the most common in clinical practice in the United States are phenytoin, levetiracetam, and valproate. At this stage of management there are a few comparative studies, but a double-blind randomized controlled trial is needed.² The definition of refractory status epilepticus (RSE) is variable, but most would agree that patients who fail first- and second-line therapy have RSE. Standard third-line therapy consists of IV anesthetics; pentobarbital was historically favored but now midazolam or propofol are more often preferred. IV anesthesia is considered so effective that some have suggested moving directly to IV anesthesia and skipping second-line therapy to avoid major time delays that could contribute to ongoing excitotoxicity and neuronal injury.