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Intravenous antiseizure medication trial for the diagnosis of nonconvulsive status epilepticus in adults

Intravenous antiseizure medication trial for the diagnosis of nonconvulsive status epilepticus in adults
Applies to: Patients with rhythmic or periodic focal or generalized epileptiform discharges on EEG with neurological impairment
Monitoring: EEG, pulse oximetry, blood pressure, ECG, respiratory rate with dedicated nurse
Antiseizure medication trial:
Sequential doses of a rapidly-acting IV antiseizure medication (eg, fosphenytoin 10 mg/kg, valproate 20 mg/kg, levetiracetam 20 mg/kg, brivaracetam 100 to 200 mg, or lacosamide 200 mg) or a short-duration benzodiazepine (eg, midazolam at 1 mg/dose)
Between doses, repeated clinical and EEG assessment
Trial is stopped after any of the following:
  • Persistent resolution of the EEG pattern (and exam repeated)
  • Definite clinical improvement
  • Respiratory depression, hypotension, or other adverse effect
  • A maximum dose is reached (such as 0.2 mg/kg midazolam, although higher doses may be needed if the patient is on chronic benzodiazepines)
Test is considered positive if there is resolution of the potentially ictal EEG pattern AND either an improvement in the clinical state or the appearance of previously-absent normal EEG patterns (eg, posterior dominant "alpha" rhythm). If EEG improves but patient does not, the result is equivocal. A negative test does not rule out NCSE.
ASM: antiseizure medication; ECG: electrocardiogram; EEG: electroencephalogram; IV: intravenous; NCSE: nonconvulsive status epilepticus.
Original figure modified for this publication. Jirsch J and Hirsch LJ. Nonconvulsive Seizures: Developing a Rational Approach to the Diagnosis and Management in the Critically Ill Population. Clin Neurophysiol 2007; 118:1660. Table used with the permission of Elsevier Inc. All rights reserved.
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