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Neurology · Topic 10 of 22

Status Epilepticus

Neurology · seizures

Status Epilepticus

A seizure past 5 minutes is status epilepticus: benzodiazepine now, second-line load if still seizing at 20 minutes, and EEG if the patient does not wake.

Key numbers
Seizure over 5 minutes is status> 5 min
Benzodiazepine first: lorazepam 0.1 mg/kg IV0.1 mg/kg (max 4 mg)
Check glucose; thiamine before dextroseglucose < 60 mg/dL
Not awake after 10 minutes: continuous EEGcEEG within 1 h
Comatose patients: at least 48 hours of cEEG≥ 48 h
01 · Defined bySeizure over 5 minutes is status

Convulsive status epilepticus = a tonic-clonic seizure lasting more than 5 minutes, or 2 or more seizures without full return of consciousness between them; it needs drug treatment, not waiting.

02 · GiveBenzodiazepine first: lorazepam 0.1 mg/kg IV

First-line therapy (5–20 min) is a benzodiazepine: IV lorazepam 0.1 mg/kg (max 4 mg/dose, may repeat once), IM midazolam 10 mg if over 40 kg, or IV diazepam 0.15–0.2 mg/kg (max 10 mg/dose).

03 · GiveSecond line: levetiracetam, fosphenytoin or valproate

If seizures continue (20–40 min), load one: fosphenytoin 20 mg PE/kg (max 1500 mg PE), valproate 40 mg/kg (max 3000 mg) or levetiracetam 60 mg/kg (max 4500 mg) — equally effective in ESETT.

01

What it is

Core idea
Nonconvulsive status: altered mental status, EEG proofNonconvulsive status epilepticus has no prominent motor activity — often only prolonged confusion or coma — and needs EEG to diagnose.
Super-refractory: failing 24 hours of anesthesiaSuper-refractory status persists despite 24 hours of general anesthesia or recurs when anesthesia is weaned; it is often due to acute encephalitis, as in new-onset refractory status epilepticus (NORSE).
02

Causes & risk factors

Why it happens
Find the cause: drug levels, metabolic, structuralLook for the cause while treating: low antiseizure drug levels or withdrawal, stroke, hypoxia, head trauma, infection and metabolic derangements (glucose, sodium, calcium, magnesium); order labs, toxicology, CT, and LP when infection is possible.
03

Diagnosis & monitoring

Work-up
Titrate infusions to EEG; hold 24–48 hoursTitrate anesthetic infusions to cessation of electrographic seizures or burst suppression, keep 24–48 hours of electrographic control, then wean slowly while watching the EEG.
Comatose patients: at least 48 hours of cEEGMonitor comatose patients with continuous EEG for at least 48 hours to detect nonconvulsive seizures, and for 24 hours after seizures stop or during antiseizure drug weaning.
04

Do right now

In this order
First moves
1
Check glucose; thiamine before dextroseglucose < 60 mg/dL
→
2
Benzodiazepine first: lorazepam 0.1 mg/kg IV0.1 mg/kg (max 4 mg)
→
3
Second line: levetiracetam, fosphenytoin or valproate
→
4
Refractory status: intubate and start propofol or midazolam
→
5
Not awake after 10 minutes: continuous EEGcEEG within 1 h
Why each step
Check glucose; thiamine before dextroseStabilize airway, breathing and circulation, start ECG monitoring and check a fingerstick glucose at once; if glucose is below 60 mg/dL give thiamine 100 mg IV, then 50 mL of D50W.
Benzodiazepine first: lorazepam 0.1 mg/kg IVFirst-line therapy (5–20 min) is a benzodiazepine: IV lorazepam 0.1 mg/kg (max 4 mg/dose, may repeat once), IM midazolam 10 mg if over 40 kg, or IV diazepam 0.15–0.2 mg/kg (max 10 mg/dose).
Second line: levetiracetam, fosphenytoin or valproateIf seizures continue (20–40 min), load one: fosphenytoin 20 mg PE/kg (max 1500 mg PE), valproate 40 mg/kg (max 3000 mg) or levetiracetam 60 mg/kg (max 4500 mg) — equally effective in ESETT.
Refractory status: intubate and start propofol or midazolamStatus that persists after a benzodiazepine and a second-line drug is refractory (about a quarter of cases): intubate and start a continuous anesthetic infusion — propofol or midazolam — under continuous EEG.
Not awake after 10 minutes: continuous EEGIf the patient has not returned to baseline 10 minutes after convulsions stop, suspect nonconvulsive status epilepticus and start continuous EEG — within 1 hour of status onset when ongoing seizures are suspected.
05

Management

Orders
No IV access: IM midazolamIn adults without established IV access, IM midazolam 10 mg is superior to IV lorazepam (AES Level A); intranasal or buccal midazolam and rectal diazepam are alternatives.
Give a full benzodiazepine doseDo not underdose benzodiazepines for fear of apnea: respiratory depression is less common with benzodiazepines than with placebo, because untreated status itself causes respiratory failure.
Fosphenytoin preferred over phenytoinFosphenytoin is preferred over phenytoin (better tolerated): infuse up to 150 mg PE/min versus phenytoin 50 mg/min, with ECG and BP monitoring for hypotension and arrhythmias; phenytoin can cause purple glove syndrome.
Control status within 60 minutesAim for definitive control within 60 minutes of onset: in adults each later drug is less effective than the one before, and the third is substantially less effective.
06

More detail

Reference
Show 7 reference facts
Focal status with impaired awareness is treated after about 10 minutes; for generalized convulsive status, lasting neuronal injury is expected beyond 30 minutes.
If none of the first-line or second-line options is available, IV phenobarbital 15 mg/kg is an alternative; it causes hypotension and respiratory depression.
Lacosamide 200–400 mg IV is an option in refractory or nonconvulsive status; it prolongs the PR interval and has few drug interactions.
Ketamine, an NMDA antagonist, is added for refractory status because GABA-receptor drugs lose efficacy as seizures persist; pentobarbital coma is the last resort (hypotension, ileus, prolonged ventilation).
Support blood pressure with vasopressors if SBP falls below 90 mmHg or MAP below 70 mmHg during treatment.
Continuous EEG finds nonconvulsive seizures in 20–60% of comatose patients, including after cardiac arrest, and in 20–35% with intracranial hemorrhage, TBI or SAH.
About 10% of patients enrolled in the ESETT trial for status epilepticus had psychogenic nonepileptic seizures — consider them when events resist every drug.
Pearl

Time is brain here too: every step later in the algorithm works less well, so give a full benzodiazepine dose early.

Sources · Glauser T et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults (American Epilepsy Society). Epilepsy Curr 2016;16:48–61 · American Epilepsy Society — Proposed Algorithm for Convulsive Status Epilepticus (2016 guideline chart) · Merck Manual Professional — Seizure Disorders (status epilepticus) · Brophy GM et al. Guidelines for the Evaluation and Management of Status Epilepticus (Neurocritical Care Society). Neurocrit Care 2012;17:3–23 · Kapur J et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus (ESETT). N Engl J Med 2019;381:2103–2113 · Farkas J. Internet Book of Critical Care (EMCrit) — Seizures and status epilepticus · Herman ST et al. Consensus statement on continuous EEG in critically ill adults and children, part I: indications (ACNS). J Clin Neurophysiol 2015 · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).