420 Viewpoint
Guidelines for the management of status epilepticus
Hervé Outina, Hugues Lefortb and Vincent Peignec;
the French Group for Status Epilepticus Guidelines
European Journal of Emergency Medicine 2021, 28:420–422
a
Service de réanimation médico-chirurgicale, Centre hospitalier intercommunal
de Poissy, Saint-Germain en Laye,  bStructure des urgences, Hôpital
d’Instruction des Armées Legouest, Metz and  cService de Réanimation, Centre
Hospitalier Métropole-Savoie, Chambéry, France
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In 2019, The French Intensive Care Society (SRLF) and
the French Society of Emergency Medicine (SFMU),
along with the Francophone Group of Resuscitation and
Paediatric Emergencies (GFRUP), have developed guide-
lines to respond to the practical questions raised by status
epilepticus management in the prehospital setting, in the
emergency department and in the ICU. Twenty-five experts
analyzed the literature and formulated recommendations
according to the Grade of Recommendation Assessment,
Development and Evaluation methodology [1].
This article reports the must-know summary of these
guidelines for the initial management of generalized
tonic-clonic status epilepticus (GTCSE) by emergency
physicians. Additional specific recommendations about
children and other types of status epilepticus are availa-
ble in the electronic appendix, Supplemental digital con-
tent 1, http://links.lww.com/EJEM/A313.
First, experts recommend that GTCSE should be
defined as a seizure that lasts at least 5  min with the
presence of continuous generalized seizure with motor
manifestations, or by the occurrence of several discrete
seizures in between which there is no complete recovery
of consciousness. The latter is defined by an inability to
answer or follow simple orders. Refractory status epilep-
ticus should be defined by status epilepticus that persists
(clinically or electrically) despite two lines of antiepilep-
tic therapy with recommended class and dosage, and ade-
quate time for onset of action.
The status epilepticus cause needs to be identified
quickly. Several causes may be responsible for a unique
status epilepticus event. Experts recommend that the
eventuality of psychogenic nonepileptic seizures should
systematically be considered throughout the manage-
ment of GTCSE.
Treatment of GTCSE must be tapered according to the
persistence of the seizures (Fig. 1). Underdosing of antie-
pileptic drugs is frequent and should be avoided [2].
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Correspondence to Vincent Peigne, MD, Service de Réanimation, Centre
Hospitalier Métropole-Savoie, Place Biset, 73000 Chambéry, France
Tel: +33 4 79 96 61 52; e-mail: vincent.peigne@ch-metropole-savoie.fr
Received 14 June 2021 Accepted 17 June 2021
Benzodiazepines have to be used as first-line treatment
of GTCSE (grade 1+): intravenous injection of 0.015 mg.
kg−1 clonazepam (1 mg for 70 kg; maximum 1.5 mg), or
an intramuscular injection of 0.15  mg.kg−1 midazolam
(10 mg for 70 kg) (grade 2+). A benzodiazepine injection
should be repeated if after 5 min following the first injec-
tion if the GTCSE persists (grade 2+).
If the GTCSE persists after 5  min following the sec-
ond injection of benzodiazepine, second-line treatment
should be administered (grade 1+). Emergency physi-
cians can use either sodium valproate (40 mg.kg−1 in 10–
15 min, maximum 3 g; another compound should be used
in women of childbearing age), fosphenytoin (20  mg.
kg−1 phenytoin equivalent, maximally at 100–150  mg.
min−1) or phenytoin (20  mg.kg−1, maximally at 50  mg.
min−1 or if >65 years: 15  mg.kg−1 and slow drip), with
cardiac monitoring (contraindicated in case of arrhyth-
mia or conduction disturbances), phenobarbital (15 mg.
kg−1, at 50–100  mg.min−1) or levetiracetam (60  mg.kg−1
over 10  min, maximum 4  g). The full prescribed dose
should be administered, even if convulsions stop (grade
2+). Prescription of antiepileptic drugs must respect
local regulations (as an example, the maximal dosing of
(fos)phenytoin is 15  mg.kg−1 phenytoin equivalent in
France).
In the case of persistent convulsive seizures 30  min
after administration of the second-line treatment
(refractory GTCSE), a coma should be rapidly induced
with a third-line general anesthetic (grade 2+). The
experts suggest that it is possible to delay coma induc-
tion using a further second-line agent if the patient has
known epilepsy and lacks any signs or symptoms of
a severe brain injury or if there are limitations to the
treatment strategy.
One of the most challenging points during GTCSE man-
agement is the decision to intubate or not the patient
[3]. Intubation may be required by the etiology of status
epilepticus (acute severe brain injury) or in the event of
refractory GCSE. The experts suggest that intubation of
a patient with GTCSE is indicated only in the case of
sustained respiratory distress (beyond a few minutes of
postcritical stertorous breathing).
DOI: 10.1097/MEJ.0000000000000857

Fig. 1
Treatment of generalized tonic-clonic status epilepticus. GTCSE, generalized tonic-clonic status epilepticus; IV, intravenous; IM, intramuscular.
Another important question addressed by the experts is
the role and timing of electroencephalography (EEG)
during GTCSE management. EEG should be performed
as soon as possible in the case of (1) no improvement
in consciousness after cessation of convulsions, (2) sus-
pected psychogenic nonepileptic seizures, metabolic or
toxic encephalopathy, subtle or refractory status. A stand-
ard EEG should be rapidly recorded after recovery of
consciousness following GTCSE.
These new recommendations should allow better man-
agement of each status epilepticus patient by emergency
physicians according to graduated and personalized pro-
tocols, modulated according to the type of status epilep-
ticus and its etiology. These guidelines update European
and American guidelines [4,5] and are in accordance with
the most recent works about emergency management of
status epilepticus [6,7]. Whether these recommendations
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Management of status epilepticus Outin et al. 421
may be applied in different settings in Europe is unknown
and warrants further evaluations.
Acknowledgements
This work was sponsored by the French Intensive Care
Society (SRLF) and the French Society of Emergency
Medicine (SFMU).
The members of the French Group for Status Epilpeticus
Guidelines: Papa Gueye, Vincent Alvarez, Stéphane
Auvin, Bernard Clair, Philippe Convers, Arielle Crespel,
Sophie Demeret, Sophie Dupont, Jean-Christophe
Engels, Nicolas Engrand, Yonathan Freund, Philippe
Gelisse, Marie Girot, Marie-Odile Marcoux, Vincent
Navarro, Andrea Rossetti, Francesco Santoli, Romain
Sonneville, William Szurhaj, Pierre Thomas, Luigi
Titomanlio, Frédéric Villega.
422  European Journal of Emergency Medicine  2021, Vol 28 No 6
Conflicts of interest
There are no conflicts of interest.
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