In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the September 2025 Emergency Medicine Practice article, Emergency Department Management of Patients With Status Epilepticus
- Topic Introduction
- Focus: Status Epilepticus in Adults
- Reference to recent pediatric episode
- Article authors: Dr. Marquez, Dr. Kaur, Dr. Lay
- Why Status Epilepticus Matters
- Teaching value and clinical challenge
- Team-based care and multidisciplinary involvement
- Guidelines and Evidence
- Review of major guidelines (International League Against Epilepsy, Neurocritical Care Society, American Epilepsy Society)
- Key trials: EcLiPSE, ConSEPT, ESETT
- Updated definition of status epilepticus
- Classification and Diagnosis
- Convulsive vs. non-convulsive status
- Importance of repeated neurologic exams
- Diagnostic challenges and mimics (e.g., syncope, psychogenic seizures)
- Etiology and Workup
- Acute vs. non-acute causes
- Common triggers: medication noncompliance, metabolic issues, infections, trauma
- Importance of sleep patterns and ammonia levels
- The NORSE acronym (new onset refractory status epilepticus)
- Prehospital and ED Management
- Airway, breathing, circulation priorities
- Early pharmacologic intervention (IM midazolam preferred in prehospital)
- Gathering history and medication information
- Positioning and airway protection
- Diagnostics
- Laboratory workup: glucose, CBC, metabolic panel, drug levels, pregnancy test
- Imaging: non-contrast CT, MRI, ultrasound, lumbar puncture
- EEG: spot vs. continuous monitoring
- Treatment Approach
- First-line: Benzodiazepines (lorazepam, midazolam)
- Second-line: Levetiracetam, valproate, fosphenytoin, phenobarbital, lacosamide
- Third-line: Continuous infusions (midazolam, propofol, pentobarbital, thiopental, ketamine)
- Dosing pearls and importance of rapid escalation
- Special Populations
- Pregnancy (eclampsia: magnesium as first-line)
- Substance-induced status epilepticus (e.g., isoniazid toxicity and pyridoxine)
- Brief mention of pediatric management and the PD stat app
- Risk Management Pitfalls
- Non-convulsive status is common and easily missed
- Importance of weight-based dosing
- Need for formal EEG in ambiguous cases
- Don’t assume non-adherence is the only cause in known epileptics
- Always consider higher level of care for status patients
- Clinical Pathway
- Stepwise approach to medication and escalation
- Emphasis on having a pathway/checklist for these high-stress cases
- Conclusion
- Recap of key points
- Thanks to authors and listeners
- Reminder to visit ebmedicine.net for CME and resources
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Sam Ashoo, MD, FACEP, is board certified in emergency medicine and clinical informatics. He serves as EB Medicine’s editor-in-chief of interactive clinical pathways and FOAMEd blog, and host of EB Medicine’s EMplify podcast. Follow him below for more…
