We explore the vagaries and nitty-gritty of drugs for seizure termination, including benzos and ASMs, with the great Tom Bleck, MD MCCM FNCS, neurointensivist, professor, and founding member of the Neurocritical Care Society.



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More reading




* Status epilepticus in the ICU




Takeaway lessons




* In the RAMPART study, IM midazolam (10 mg) achieved faster seizure control than IV lorazepam (4 mg), with most of the difference accounted for by the time needed to start the line. So if there’s no IV, use IM midazolam.



* If there is an IV, there is no data on superiority of any benzo over any other. This makes it appealing to use lorazepam, simply because we have the most data surrounding its use. But use whatever.



* It is often hard to truly know the timeline since seizures began, other than those already on EEG monitoring. Probably in many published populations, non-benzo-responders may have been patients who were already seizing for some time. As soon as seizures begin, benzo-sensitive gaba A receptors immediately begin to be replaced by benzo-insensitive receptors (a phenomenon not seen when benzos are used for other applications).



* Most seizures, even in the ICU, end in about 90 seconds. If you don’t witness the onset, you should probably plan to treat it. If you do, you should prepare to treat, but wait five minutes to see if it stops, our current cutoff for status epilepticus—most will stop before then. The caveat is that it’s not impossible some of these people who appear to stop convulsing have simply become non-convulsive… this generally takes longer (30+ minutes), but in critically ill patients all bets are off.



* Meaningful respiratory dysfunction from benzos for seizures is vanishingly rare. Most patients who get intubated due to benzo-related sedation do so out of clinician preference, not true need. Consider a side-lying rescue position to maintain the airway, or an oral or nasal airway.



* The VA Cooperative trial used a lorazepam dose of 0.1 mg/kg, one time, no cap. Most of the current guidelines now suggest giving a 4 mg dose, then repeating if necessary. If this still leaves you under 0.1 mg/kg, a third dose to finish it out is reasonable. Giving more than 0.1 mg/kg is probably not more effective. Six minutes between doses is sometimes recommended, but most would go closer to 4-5 minutes at most.



* The goal is cessation of convulsions, or of any other clinical signs of seizure (twitches, eye deviation, etc). Ideally, the patient would then wake up promptly, but this is a rarity, especially in the ICU. This then leaves the question of whether the patient is still seizing, merely non-convulsively. This needs an EEG to answer, but the risk to the brain once convulsions cease is probably less, so you can probably wait for the EEG (rather than giving more empiric doses of benzos).



* If not rousing, however, you should probably treat with an anti-seizure medication, unless rapid access to EEG can prove lack of ongoing seizure. The three studied in the ESETT trial were: levetiracetam 60 mg/kg, valproate at 40 mg/kg, or fosphenytoin at 20 mg/kg, all of which had about 40% response rate. This was used in patients still convulsing at the time,