Drug treatment in status epilepticus - Misconceptions, facts and perspectives

The status epilepticus (SE) of generalized tonic-clonic seizures still is a life-threatening condition with a mortality rate up to 25%. Early aggressive treatment is absolutely necessary, as recent data show a decrease of mortality under 5% when adequate therapy is established within 30-60 minutes. Additional determinants of had prognosis ore age, underlying hypoxemia and the presence of a "subtle". Unfortunately, the exact pathophysiology and the incidence of SE (lack of definition and classification) ore still unclear. There is experimental evidence for receptor modulation during ongoing SE, explaining some failures of antiepileptic drugs (AED). There is need for more systematic prospective studies. An ideal AED for SE should be easy to administer, have both an acute and long-testing anti-seizure effect and present with a minimum of side effects. All current AEDs do not fulfill this ideal. Because of this, a decision algorithm is still necessary combining different iv AEDs in a fast systematic sequence in a narrow time window <60 minuter. If this is not successful, general anesthesia has to be established. The different pharmacokinetic profiles of the first choice drugs diazepam, clonozepam, lorozepam and midazolam have to be considered. The most frequent route of subsequent phenytoin or phenobarbital might be substituted in the future by the less side-effect carrying prodrug fosphenytoin and iv valproate which showed promising results in our own experience. For drugresistant SE propofol, lidocaine and ketamine chloride are interesting alternative drugs.