Diazepam that can be inserted rectally is often prescribed to caregivers of people with epilepsy. This enables treatment of multiple seizures prior to being able to seek medical care. Benzodiazepines are the preferred initial treatment after which typically phenytoin or fosphenytoin is given. First aid guidelines for seizures state that, as a rule, an ambulance should be called for seizures lasting longer than five minutes (or sooner if this is the person's first seizure episode and no precipitating factors are known, or if SE happens to epileptic person whose seizures were previously absent or well-controlled for a considerable time). Benzodiazepines When given intravenously, lorazepam appears to be superior to diazepam for stopping seizure activity. Intramuscular midazolam appears to be a reasonable alternative especially in those who are not in hospital. The benzodiazepine of choice in North America for initial treatment is lorazepam, due to its relatively long duration of action (2–8 hours) when injected, and particularly due to its rapid onset of action, which is thought to be due to its high affinity for GABA receptors and low lipid solubility. This causes the drug to remain in the vascular compartment. If lorazepam is not available, or intravenous access is not possible, then diazepam should be given. Alternatively, medication, such as glucagon, should be given through the bone (intraosseously). In several countries outside North America, such as the Netherlands, intravenous clonazepam is regarded as the drug of first choice. Cited advantages of clonazepam include a longer duration of action than diazepam and a lower propensity for the development of acute tolerance than lorazepam. The use of clonazepam for this indication is not recognized in North America, perhaps because it is not available as an intravenous formulation there. Particularly in children, another popular treatment choice is midazolam, given into the side of the mouth or the nose. Sometimes, the failure of lorazepam alone is considered to be enough to classify a case of SE as refractory–that is, resistant to treatment. Phenytoin and fosphenytoin Phenytoin was once another first-line therapy, although the prodrug fosphenytoin can be administered three times as fast and with far fewer injection site reactions. If these or any other hydantoin derivatives are used, then cardiac monitoring is necessary if they are administered intravenously. Because the hydantoins take 15–30 minutes to work, a benzodiazepine or barbiturate is often coadministered. Because of diazepam's short duration of action, they were often administered together anyway. At present, these remain recommended second-line, follow-up treatments in the acute setting per guidelines by groups like Neurocritical Care Society (United States). Barbiturates Before the benzodiazepines were invented, barbiturates were used for purposes similar to benzodiazepines in general. Some are still used today in SE, for instance, if benzodiazepines or the hydantoins are not an option. These are used to induce a barbituric coma. The barbiturate most commonly used for this is phenobarbital. Thiopental or pentobarbital may also be used for that purpose if the seizures have to be stopped immediately or if the person has already been compromised by the underlying illness or toxic/metabolic-induced seizures; however, in those situations, thiopental is the agent of choice. That said, even when benzodiazepines are available, certain algorithms–including in the United States–indicate the use of phenobarbital as a second- or third-line treatment in SE. Such use is adjunctive. At least one U.S. study showed phenobarbital, when used alone, controlled about 60% of seizures, hence its preference as an add-on therapy. Carbamazepine and valproate Valproate is available to be given intravenously, and may be used for<unk> . Carbamazepine is not available in an intravenous formulation, and does not play a role in<unk> . Others If this proves ineffective or if barbiturates cannot be used for some reason, then a general anesthetic such as propofol may be tried; sometimes it is used second after the failure of lorazepam. This would entail putting the person on artificial ventilation. Propofol has been shown to be effective in suppressing the jerks seen in myoclonus<unk> . Ketamine, an NMDA antagonist drug, can be used as a last resort for drug-resistant<unk> . Lidocaine has been used in cases that do not improve with other more typical medications. One concern is that seizures often begin again 30 minutes after it is stopped. Additionally, it is not recommended in those with heart or liver problems.
Status epilepticus
Delirium
Reflex seizure
Meningitis
Complex partial status epilepticus
Psychogenic non-epileptic seizure
Emergence delirium
Intercalated seizure