Pharmacology  ·  Anti-Seizure Drugs

Status Epilepticus and Special Populations

Emergency protocol, pregnancy, elderly, and neonatal prescribing

• Status epilepticus is a pharmacological emergency: every minute of untreated convulsive status epilepticus causes additional neuronal injury, and the probability of stopping seizures with any given intervention falls as time increases. The three-step protocol is not a recommendation to sequence drug classes thoughtfully over hours — it is a time-driven algorithm where each step has a defined cutoff measured in minutes.
• The protocol is organized by mechanism, not by drug. Step 1 is a gamma-aminobutyric acid enhancer. Step 2 is a sodium channel blocker or SV2A modulator. Step 3 is anesthetic induction. That mechanistic sequence reflects both pharmacological logic and escalating clinical invasiveness, not arbitrary convention.
• Intramuscular midazolam outperforming intravenous lorazepam in the RAMPART trial needs to land clearly: the advantage of intramuscular midazolam in prehospital status epilepticus is access speed, not pharmacology. Intravenous access in a convulsing patient in the field takes time that intravenous lorazepam then needs to catch up from.
• The pregnancy card is a ranking exercise rooted in the teratogenicity evidence across the chapter. Lamotrigine and levetiracetam are preferred. Valproate sits at the worst end. Carbamazepine is intermediate. These rankings come from registry data and the NEAD study — not from animal models — and should be applied to actual prescribing decisions, not only to examinations.
• The elderly and neonatal cards close the chapter by showing how the same mechanistic framework produces different clinical decisions when physiology changes. Lower doses, fewer interactions, and avoiding cognitively burdensome agents in the elderly; phenobarbital as standard-of-care in neonates because it is the best-studied agent in that developmental window.