Guidance

7 Treating status epilepticus, repeated or cluster seizures, and prolonged seizures

7 Treating status epilepticus, repeated or cluster seizures, and prolonged seizures

7.1 Status epilepticus

Valproate: NICE is assessing the impact of the following Medicines and Healthcare products Regulatory Agency (MHRA) drug safety updates on recommendations in this guideline:

Initial treatment for generalised convulsive status epilepticus

7.1.1

Provide resuscitation and immediate emergency treatment for children, young people and adults who have convulsive status epilepticus (seizures lasting 5 minutes or more).

7.1.2

If the person with convulsive status epilepticus has an individualised emergency management plan that is immediately available, administer medication as detailed in the plan.

7.1.3

If the person with convulsive status epilepticus does not have an individualised emergency management plan immediately available:

  • give a benzodiazepine (buccal midazolam or rectal diazepam) immediately as first-line treatment in the community or

  • use intravenous lorazepam if intravenous access and resuscitation facilities are immediately available.

7.1.4

Be aware of the possible underlying causes of status epilepticus, including hypoglycaemia, eclampsia and alcohol withdrawal, which may need to be treated with additional medication.

7.1.5

Be alert to non-adherence to antiseizure medication, which can also be a cause of status epilepticus.

7.1.6

Be aware that non-epileptic seizures (dissociative seizures) can be similar in presentation to convulsive status epilepticus.

Management if initial treatment is unsuccessful

7.1.7

If convulsive status epilepticus does not respond to the first dose of benzodiazepine:

  • call emergency services in the community or

  • seek expert guidance in hospital.

7.1.8

Continue to follow the person's individualised emergency management plan, if this is immediately available, or give a second dose of benzodiazepine if the seizure does not stop within 5 to 10 minutes of the first dose.

7.1.9

If convulsive status epilepticus does not respond to 2 doses of a benzodiazepine, give any of the following medicines intravenously as a second-line treatment:

7.1.10

If convulsive status epilepticus does not respond to a second-line treatment, consider trying an alternative second-line treatment option under expert guidance.

7.1.11

If convulsive status epilepticus does not respond to the second-line treatment options tried, consider the following third-line options under expert guidance:

  • phenobarbital or

  • general anaesthesia.

7.1.12

After an episode of convulsive status epilepticus, agree an emergency management plan with the person if they do not already have one and there is concern that status epilepticus may recur.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on status epilepticus.

Full details of the evidence and the committee's discussion are in evidence review 9: antiseizure medication for status epilepticus.

7.2 Repeated seizures or cluster seizures

7.2.1

Manage repeated or cluster seizures (typically 3 or more self-terminating seizures in 24 hours) as a medical emergency.

7.2.2

If a person has repeated or cluster seizures:

  • follow their individualised emergency management plan, if this is immediately available or

  • consider giving a benzodiazepine, such as clobazam or midazolam, immediately if they do not have an individualised emergency management plan immediately available.

7.2.3

Seek expert guidance if the person has further episodes of repeated or cluster seizures.

7.2.4

Agree an individualised emergency management plan with the person after repeated or cluster seizures if they do not have one already and there is concern that repeated or cluster seizures may recur.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on repeated or cluster seizures.

Full details of the evidence and the committee's discussion are in evidence review 10: antiseizure medications for repetitive/cluster seizures: monotherapy and add-on therapies.

7.3 Prolonged seizures

For convulsive seizures that continue for 5 minutes or more, follow the recommendations in the section on status epilepticus.

7.3.1

Manage prolonged convulsive seizures (any convulsive seizure that continues for more than 2 minutes longer than a person's usual seizure) as a medical emergency.

7.3.2

If a person has a prolonged convulsive seizure:

  • follow their individualised emergency management plan if this is immediately available or

  • consider giving a benzodiazepine, such as midazolam or clobazam, immediately if they do not have an individualised emergency management plan immediately available.

7.3.3

After a prolonged convulsive seizure, agree an emergency management plan with the person if they do not already have one and there is concern that prolonged convulsive seizures may recur.

7.3.4

After a prolonged non-convulsive seizure (a non-convulsive seizure that continues for more than 2 minutes longer than a person's usual seizure), agree an emergency management plan with the person if they do not already have one and there is concern that prolonged non-convulsive seizures may recur.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on prolonged seizures.

Full details of the evidence and the committee's discussion are in evidence review 11: antiseizure medication for prolonged seizures: monotherapy.