Status Epilepticus: Stop the Seizure

• Convulsive seizure ≥5 min, or repeated seizures without recovery: lorazepam 0.1 mg/kg IV (max 4 mg; repeat once after 5 min), or midazolam 10 mg IM if >40 kg with no IV access (5 mg at 13–40 kg). If an adequate benzodiazepine fails, load a second-line drug straight away.
• ESETT: levetiracetam 60 mg/kg (max 4500 mg), fosphenytoin 20 mg PE/kg (max 1500 mg PE) and valproate 40 mg/kg (max 3000 mg), each IV over 10 min, worked equally well. Pick one by contraindications and monitoring needs.
• Still seizing after an adequate benzodiazepine and a second-line load = refractory: get ICU and neurology now, intubate if needed, and start an EEG-guided anaesthetic infusion. Do not wait for the 40-min mark if treatment has already failed.
• 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
• Still seizing after an adequate benzodiazepine dose? Load ONE IV drug straight away: levetiracetam 60 mg/kg (max 4500 mg), fosphenytoin 20 mg PE/kg (max 1500 mg PE), or valproate 40 mg/kg (max 3000 mg), each over 10 min, with cardiac and respiratory monitoring. Check contraindications first.
• Still seizing after an adequate benzodiazepine and a second-line load?
• Yes
• 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
• No
• 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

• Clinical or EEG seizures continuing despite an adequate benzodiazepine and a properly dosed second-line drug = refractory status epilepticus.
• 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?
• Yes
• 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
• Keep the EEG running throughout the infusion and for at least 24 h after the anaesthetic stops — longer if seizures return or the examination is still unreliable. Continue scheduled antiseizure drugs.
• No
• Seizures uncontrolled: ongoing seizures despite rising infusion rate (treatment failure), breakthrough seizures after initial control, or recurrence when weaning the infusion
• Get urgent neurocritical-care review. Optimise or change the anaesthetic (e.g. propofol or pentobarbital) under continuous EEG, support BP, and add maintenance antiseizure drugs. Set the target — seizure suppression or burst suppression — case by case. Therapeutic hypothermia is not routine.