UMEM Educational Pearls

Category: Neurology

Title: Are We Underdosing Benzodiazepines in Status Epilepticus?

Keywords: seizure, status epilepticus, benzodiazepine, antiepileptic, failure (PubMed Search)

Posted: 6/12/2019 by WanTsu Wendy Chang, MD
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  • Benzodiazepines are first-line treatment for status epilepticus.
  • Guidelines for the treatment of status epilepticus recommend dosing as:
    • 10 mg midazolam IM for patients > 40 kg or 5 mg midazolam IM for patients 13-40 kg
    • 0.1 mg/kg lorazepam IV (max 4 mg/dose), can repeat x 1
    • 0.15-0.2 mg/kg diazepam IV (max 10 mg/dose), can repeat x 1
  • The recent Established Status Epilepticus Treatment Trial (ESETT) compared the treatment of patients who did not respond to benzodiazepines.
    • Overall, 29.8% of the first dose of benzodiazepines given in the ED met minimum dose recommendations.
    • Dosing for patients < 40 kg more frequently met minimum dose recommendations.
    • This study found a pattern of multiple, small doses instead of a single full dose of benzodiazepine as recommended by guidelines.

Bottom Line: Underdosing of benzodiazepines in status epilepticus may contribute to treatment failure.


  • Sathe AG, Tillman C, Coles LD, et al. Underdosing of benzodiazepines in patients with status epilepticus enrolled in Established Status Epilepticus Treatment Trial. Acad Emerg Med. 2019 Jun 4. [Epub ahead of print]
  • Brophy GM, Bell R, Claasen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17(1):3-13.
  • Glauser T, Shinnar S, Gloss D, et al. American Epilepsy Society Guideline Evidence-Based Guideline: Treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61.

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