one of several drugs including phenytoin or fosphenytoin, valproate, or levetiracetam [55–59]. The recently completed ESETT trial for benzodiazepine refractory status epilepticus suggested that these drugs were of equivalent efficacy [60]. While these agents are not generally available in typical EMS environments, they may be found in critical care transport situations and EMS physician response teams. There is a trend in recent guidelines to deemphasize barbiturates in favor of levetiracetam, fosphenytoin, or valproate.
Refractory status epilepticus may be defined as generalized seizures that persist through administration of optimal benzodiazepines and a second‐line drug. There are no prospective, randomized trials to guide third‐line therapy. Anecdotal reports and recommendations list a variety of other agents, including high‐dose phenytoin [57], lidocaine [61–64], etomidate [65], ketamine [66, 67], midazolam [68, 69], propofol [69–73], and valproic acid [74–76]. There is a trend in the literature to recommend propofol for refractory generalized convulsive status epilepticus that fails to respond to optimal benzodiazepine and a second‐line drug administration. Definitive airway management and blood pressure support will be needed with the use of many of these agents.
Conclusion
Seizures are one of the most common conditions resulting in EMS activation. In many cases, the patient is recovering consciousness at the time of EMS arrival, and little if any care is needed. However, generalized convulsive status epilepticus represents an emergency with early interventions potentially limiting morbidity. After brief diagnostic intervention to confirm seizures, prompt treatment of persistent or recurrent generalized convulsions with benzodiazepines is indicated. A variety of treatment options is available for route of administration and drug choices. Retrospective review and commentary urge not delaying anticonvulsant administration in cases of generalized convulsive status epilepticus [77, 78]. Persistent convulsions will require additional ALS interventions.
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