UPDATES IN THE MANAGEMENT OF STATUS EPILEPTICUS IN THE EMERGENCY DEPARTMENT: A REVIEW OF EVIDENCE-BASED GUIDELINES AND NOVEL AGENTS

Status epilepticus (SE) is a time-critical neurological emergency associated with significant morbidity and mortality, requiring prompt and structured management in the emergency department (ED). This narrative review synthesizes the current evidence and recent advancements in the management of SE, with a particular focus on updates to evidence-based guidelines and the integration of novel pharmacological agents. A systematic literature search was conducted using PubMed, MEDLINE, Scopus, and Cochrane databases for articles published between 2013 and 2024, alongside seminal earlier works. The review outlines the imperative for rapid stabilization and the unchallenged role of benzodiazepines as first-line therapy, emphasizing the importance of non-IV formulations like intramuscular and intranasal midazolam to reduce time-to-treatment. It further explores the evolution of second-line therapy, where levetiracetam, valproate, and fosphenytoin are now established as equally effective options, enabling a more personalized approach to care. The management of refractory and super-refractory SE is discussed, highlighting the critical role of continuous EEG monitoring and the emerging use of ketamine to overcome GABAergic resistance. Furthermore, the review addresses the diagnostic challenges of nonconvulsive SE and adaptations required for special populations. By comparing guidelines from the American Epilepsy Society and the Neurocritical Care Society, this paper provides a clear roadmap for ED clinicians, reconciling differences and underscoring the principle that "time is brain." Finally, we conclude by identifying key challenges and future directions for research, including the optimization of protocols, the need for prospective trials on novel agents, and the move towards personalized medicine in SE management. Keywords: Status Epilepticus; Emergency Department; Management; Guidelines; Benzodiazepines; Neurological Emergency