Emergency Treatment of Status Epilepticus in Hospital

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The principles underlying the in-hospital treatment of status epilepticus in people with or without ID are no different. However, as already discussed, status epilepticus appears to be more common and more difficult to treat in people with ID. It is worth repeating the point that has already been made about the importance of treating promptly, not only because it decreases the probability of brain damage but also because the status epilepticus seems to be much more responsive to treatment if the latter is given early. Prompt treatment can avoid the more difficult-to-treat established status epilepticus. If prompt out-of-hospital treatment is given by the parent or caregiver, hospital treatment may be avoided altogether. However, if treatment in the emergency room, general ward, or intensive care unit is required, there are well-established protocols that can be followed.19,35-37 These generally recommend that if treatment with full doses of a benzodiazepine such as diazepam, lorazepam, clonazepam, or midazolam via the rectal/buccal or parenteral route have not been effective, then a phenytoin/fosphenytoin infusion should be commenced, typically in a dose of 18mg/kg phenytoin or equivalent. If this fails to control the status epi-lepticus a barbiturate and/or anesthetic agent may be used. However, while working in an epilepsy center with an emergency room but no on-site intensive care facilities, I have found that other strategies can be useful. As already stated, rectal paral-dehyde can be effective when benzodiazepines have failed. Another option is intravenous chlormethiazole, which can be very effective when other drugs have not controlled the status epilepticus. There have been concerns about the possibility of life-threatening respiratory depression with this drug, but if it is injected slowly by the doctor, rather than being left as an intravenous drip (with the potential of excessive doses being given unsupervised), it is, in my experience, both safe and valuable.

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