Case-Based Modules > Case 14 > Conclusion

Great job! The patient had a TBI that ended up having intracranial hypertension, but not before developing more overt generalized convulsive status epilepticus. We had to progress through the usual algorithm to stop it, and once we stabilized him from that perspective, we were able to proceed with other key measures like invasive ICP monitoring, and, of course, cEEG.

Pearl 1: The first-line therapy for convulsive status epilepticus is IV lorazepam or IM midazolam.

With IV lorazepam, the overall target dose is 0.1mg/kg, though the recommended maximum dose given at a time is 4mg. Time to action for IV lorazepam is about 3 minutes. IM midazolam 10mg is recommended if IV access is not already established. Time to action for IM midazolam is about 5-10 minutes.


Pearl 2: The second-line agents for convulsive status epilepticus are IV levetiracetam 60mg/kg (max 4500mg), IV fosphenytoin 20mg PE/kg (max 1500mg PE), and IV valproic acid 40mg/kg (max 3000mg).

These three ASMs are roughly equivalent in efficacy for all comers. Of course, if you have information about their current medications (such as ASMs or other drugs that may be rife with drug-drug-interactions), use that knowledge in selecting which ASM to use. Otherwise, it helps to be familiar with which is most easily obtained; levetiracetam is usually the answer.

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