Rationale: you have 30 minutes from now to have the status broken or to have the person under general anesthesia.
TIME: 0 minutes
3. Have someone call anesthesia.
Rationale: if you can't break this patient, the anesthesiologist has to be down there with pentothal in hand, in 30 minutes. Give him/her fair warning.
TIME: 1 minute
4. Start an IV and give:
an ampule of D50 (25 cc of 50% dextrose/water)
100 mg thiamine
have someone else start a second IV
Rationale: hypoglycemia can cause status epilepticus.
TIME: 3 minutes
5. If status doesn't break, then give:
1 mg ativan IV every minute for 10 minutes
simultaneously, 18 mg/kilo of phenytoin IV at <50 mg/minute (have EKG hooked up)
Rationale: benzodiazepines are great for breaking seizures, phenytoin (Dilantin) excellent IV seizure medication also. Both are quickly available in ER.
TIME: 15 minutes
6. If status doesn't break, then give:
phenobarbital IV, 20 mg/kilo at < 100 mg/minute
Rationale: phenobarbital is also an excellent IV seizure medication. Also quickly availabe in ER.
TIME: 25 minutes
7. If status doesn't break, then GENERAL ANESTHESIA NOW:
pentobarbital, 10 mg/kilo load then 1 mg/kilo/h until EEG shows burst-suppression
by the way, this means intubation and mechanical ventilation
Rationale: these neurons have to be stopped before irreversible damage occurs.
Keep patient down for 24 h, make sure EEG shows the seizures well and truly stopped, then try tapering off the pentobarbital with lots of other seizure meds on board and more pentobarb standing by.
NOTE: all these depressants may cause cardiac depression too, so be ready to support blood pressure. This means that these people need >= 2 good IVs, one for seizure meds, the other for all the other stuff.
