Management of Status Epilepticus in the Prehospital Setting, in the Emergency Department and in Intensive Care Unit (Except Newborns)

Management of status epilepticus (SE) is subject to many difficulties: diagnosis, etiological investigation, non-specific and specific treatment. The French Society of Intensive Care and the French Society of Emergency Medicine, with the French Group for Pediatric Intensive Care and Emergencies, have developed guidelines to respond to the practical questions raised by SE management in the prehospital setting, in the emergency department and in the intensive care unit. Twenty-five experts analyzed the literature and formulated recommendations according to the Grade of Recommendation Assessment, Development and Evaluation methodology. The experts agreed on 96 recommendations. Recommendations with the strongest level of evidence concern only generalized tonic convulsive SE. In this setting, first-line use of benzodiazepines (direct intravenous clonazepam or intramuscular midazolam) was recommended, with a second injection in the case of clinical persistence of SE five minutes after the first injection. In the case of persistence of SE five minutes after this second injection, the recommendation is to administer the second-line treatment: sodium valproate, (fos)phenytoin, phenobarbital or levetiracetam. The confirmed persistence of convulsions 30 min after the beginning of the administration of this second-line treatment defines refractory SE. At this stage, a coma should be rapidly induced by means of a third-line general anesthetic (midazolam and/or propofol). Additional specific recommendations focus on children (except newborns) and on other types of SE.