UMEM Educational Pearls

Title: Are We Underdosing Benzodiazepines in Status Epilepticus?

Category: Neurology

Keywords: seizure, status epilepticus, benzodiazepine, antiepileptic, failure (PubMed Search)

Posted: 6/12/2019 by WanTsu Wendy Chang, MD
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Benzodiazepines are first-line treatment for status epilepticus.
Guidelines for the treatment of status epilepticus recommend dosing as:
- 10 mg midazolam IM for patients > 40 kg or 5 mg midazolam IM for patients 13-40 kg
- 0.1 mg/kg lorazepam IV (max 4 mg/dose), can repeat x 1
- 0.15-0.2 mg/kg diazepam IV (max 10 mg/dose), can repeat x 1
The recent Established Status Epilepticus Treatment Trial (ESETT) compared the treatment of patients who did not respond to benzodiazepines.
- Overall, 29.8% of the first dose of benzodiazepines given in the ED met minimum dose recommendations.
- Dosing for patients < 40 kg more frequently met minimum dose recommendations.
- This study found a pattern of multiple, small doses instead of a single full dose of benzodiazepine as recommended by guidelines.

Bottom Line: Underdosing of benzodiazepines in status epilepticus may contribute to treatment failure.

Sathe AG, Tillman C, Coles LD, et al. Underdosing of benzodiazepines in patients with status epilepticus enrolled in Established Status Epilepticus Treatment Trial. Acad Emerg Med. 2019 Jun 4. [Epub ahead of print]
Brophy GM, Bell R, Claasen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17(1):3-13.
Glauser T, Shinnar S, Gloss D, et al. American Epilepsy Society Guideline Evidence-Based Guideline: Treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61.

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