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usually prevent the evolution into true status epilepticus. If regular AED treatment has been
reduced or stopped by patient or doctor, this should be reinstated. Rectal diazepam was the
drug of choice. A dose of 0.51 mg/kg rectal diazepam solution results in therapeutic serum
concentrations within one hour, and has been shown to be very effective in arresting acute
seizures with minimal side effects.

However, a disadvantage of rectal diazepam is difficulty with and concern about the route of
administration, especially in children so alternatives have been sought. Midazolam has the
advantage over other benzodiazepines in that it can be administered by intranasal, buccal and
intramuscular routes. Buccal midazolam (10 mg in 2 ml) has shown superiority

Table 2. Suggested emergency antiepileptic drug regimen for status in newly presenting adult
patients.

Premonitory stage (pre- Midazolam 10 mg given buccally
hospital)

If seizures continue, treat as below

Early status Lorazepam (i.v.) 0.07 mg/kg (usually a 4 mg bolus, repeated
Established status once after 1020 minutes; rate not critical)

If seizures continue 30 minutes after first injection, treat as
below

Phenytoin infusion at a dose of 1518 mg/kg at a rate of 50
mg/minute or fosphenytoin infusion at a dose of 1520 mg
PE/kg at a rate of 150 mg PE/minute

or

Valproate infusion at a dose of 20–30 mg/kg

and/or

Phenobarbitone bolus of 10 mg/kg at a rate of 100 mg/minute
(usually 700 mg over seven minutes in an adult)

Refractory status General anaesthesia, with either propofol, midazolam or

thiopentone. Anaesthetic continued for 1224 hours after the last
clinical or electrographic seizure, then dose tapered

In the above scheme, the refractory stage (general anaesthesia) is reached 60/90 minutes after the initial
therapy. This scheme is suitable for usual clinical hospital settings. In some situations, general
anaesthesia should be initiated earlier and, occasionally, should be delayed.