Introduction

Status epilepticus (SE) often begins outside the hospital (1, 44). Overall, SE is similar in this setting, but there is a higher incidence of cases resulting from drug withdrawal and acute toxic and metabolic derangements than in the hospital (1, 12, 44). Although the goal of rapid seizure termination is still key outside of the hospital, a number of practical issues, particularly the absence of physicians and difficulties in rapidly obtaining access for intravenous (IV) drug administration, often mandate a different treatment approach.

Early treatment of SE has been shown not only to reduce seizure duration but also to improve the response to medication (32, 33). Most treatment protocols and randomized studies of the treatment of generalized SE have been in hospitalized patients (30, 50, 53). SE, however, often begins in homes, public places, and residential care facilities, with the patients then transported to the hospital, imposing a significant treatment delay.

Rapidly acting agents such as benzodiazepines can be administered by nonphysicians. Concerns over nonphysician administration include the potential for respiratory depression, hypotension, and inappropriate administration due to misdiagnosis of SE (32). Route of administration is also a key issue; IV administration may lead to a quicker onset of drug action but a higher risk of respiratory compromise. In addition, delay due to difficulty in obtaining IV access by inexperienced medical support staff may negate the advantages of this route. Rectal, intranasal, buccal, intramuscular (IM), and subcutaneous routes have been used as alternatives, particularly when the drug is administered by the patient's family or by staff at long-term care facilities.