Status Epilepticus: Stop the Seizure

• Seizing for 5 min = status: give lorazepam 0.1 mg/kg (max 4 mg ×2) or midazolam 10 mg IM; move to second-line at 20 min.
• ESETT: LEV 60 mg/kg = fosphenytoin 20 mgPE/kg = valproate 40 mg/kg, all equal; pick one and load fully.
• Refractory >40 min: intubate and run midazolam/propofol infusion on EEG; non-convulsive SE is common.
• Find the cause: glucose, AED levels, Na, tox, CT, LP ± autoimmune.

Early Management of Status Epilepticus

• Status epilepticus: single seizure ≥5 min, or recurrent seizures without regaining consciousness
• 0–5 min window: ABCs, side-lying position, O₂, IV access, fingerstick glucose (+ thiamine), labs, AED levels, begin the timer
• 5–15 min window: lorazepam 0.1 mg/kg IV (max 4 mg/dose, one repeat allowed) — if no IV access, midazolam 10 mg IM
• At 15–30 min, load second-line: valproic acid 40 mg/kg, fosphenytoin 20 mgPE/kg, or levetiracetam 60 mg/kg (max 4,500 mg)
• Seizures still going past 30–40 min?
• Intubate, start continuous EEG, then midazolam 0.2 mg/kg bolus followed by 0.05–2 mg/kg/h infusion, OR propofol — titrated to seizure suppression/burst suppression
• Continue therapy 24–48 h; wean slowly under EEG monitoring
• Keep up second-line maintenance dosing; work up the cause; EEG if not awakening as expected
• Etiology workup: hypoglycemia · hyponatremia · AED noncompliance · CNS infection · stroke · toxidrome · eclampsia (MgSO₄); fluids/pressors for load-related hypotension

Managing Refractory Status Epilepticus

• Seizures persist (clinically or on EEG) despite two+ anticonvulsants
• General care: intubate to protect airway · continuous EEG monitoring · close hemodynamic monitoring · fluids and vasopressors prn · keep maintenance AEDs (e.g., phenytoin, levetiracetam) at high therapeutic levels · treat the underlying cause · consider neurology consultation
• Controlling seizures: start infusion targeting clinical and electrographic seizures, e.g., midazolam · loading bolus of the same agent allowed (e.g., at intubation) for rapid control · titrate infusion to keep seizures controlled
• Seizures controlled?
• Keep infusion running 24 hours at the rate that hit target · watch closely for treatment complications (infections, hemodynamic instability, ileus) · after 24 hours gradually wean the infusion off and watch for seizure recurrence
• Once refractory status epilepticus is controlled: keep the EEG running 12–24 hours off all infusions · continue the other AEDs
• Seizures uncontrolled: ongoing seizures despite rising infusion rate (treatment failure), breakthrough seizures after initial control, or recurrence when weaning the infusion
• Burst suppression: switch to alternate agent (e.g., propofol, pentobarbital) aiming for burst suppression · consider therapeutic hypothermia · add more enteral AEDs (e.g., topiramate, lacosamide)