Status epilepticus
Status epilepticus is seizure activity lasting 5 minutes, or seizures without return to baseline in between. Past 5 minutes it is unlikely to stop on its own — treat early, in parallel, and definitively within the hour.
01 / Key points
Definition and stakes
- Definition: 5 minutes, or not returning to baseline between seizures.
- If >5 minutes, unlikely to stop on its own.
- Don’t forget about non-convulsive status epilepticus (NCSE).
- EEG is ideal and needed once the patient has stabilized clinically.
- Mortality is 20% or more; in the ICU, in continuous status >72 hours, mortality can exceed 60% — even 80%.
Time targets
Once the benzodiazepine dose is given, start the antiseizure medication (AED) at the same time — bring it on as soon as possible. Treatment should be achieved within 60 minutes of onset; definitive. Transfer the patient to ICU (level 1/2/3).
02 / Management
Abortive and urgent control therapy
| Stage | Agent | Dose | Notes |
|---|---|---|---|
| Initial abortive | IV lorazepam (ideal) | 2–4 mg IV ×1; repeat ×2, q5 min | Prepare for airway management; consider less for very frail patients |
| Initial abortive | IM midazolam (ideal; found as effective as IV lorazepam) | 5–10 mg IM, or 5–10 mg IV; when going IM, 10 mg IM is suggested; ×2 doses, q5 min | Consider the patient; intranasal is an option — less respiratory suppression, but caution with dose and monitor the patient |
| Urgent control (AED) | Phenytoin | 20 mg/kg IV load | Check trough level after 24 h; consider drug interactions with other agents |
| Urgent control (AED) | Valproate (VPA) | 25–40 mg/kg IV load; suggest 40 mg/kg IV ×1; don’t exceed 2,500 mg | Study suggests similar to phenytoin; check trough level after 24 h; consider LFTs and ammonia |
| Urgent control (AED) | Levetiracetam | 40–60 mg/kg over 10 min; don’t exceed 4.5 g IV ×1 for the first dose | Adjust for renal clearance |
- Why not infuse lorazepam? (a) precipitation risk; (b) lactic acidosis from accumulation of propylene glycol, used as a diluent in high-dose IV lorazepam.
- The ESETT trial compared several AEDs for established status epilepticus and found no difference between agents.
03 / Slides
SiLab status epilepticus deck
04 / Reading
Guidelines and reviews
- PDF · jcm-05-00049.pdfFalco-Walter JJ, Bleck T. Treatment of established status epilepticus. J Clin Med. 2016;5(5):49.
Open the PDF (Google Drive) ↗ · DOI ↗ - PDF · encephalitis-2022-00087.pdfByun JI. Management of convulsive status epilepticus: recent updates. Encephalitis. 2023;3(2):39–43.
Open the PDF (Google Drive) ↗ · DOI ↗ - PDF · SE_Guidelines_NCS_0412.pdfBrophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17(1):3–23.
Open the PDF (Google Drive) ↗ · DOI ↗ - PDF · Management of Status Epilepticus 2022.pdfBirrer K, et al. Management of status epilepticus in adults — evidence-based medicine guideline. SurgicalCriticalCare.net (Orlando Regional Medical Center); approved 27 July 2022.
Open the PDF (Google Drive) ↗