Generalised tonic-clonic seizure ongoing at 7 minutes — treat the clock: benzodiazepine at 5 min, second-line loaded by 20 min, airway by 30–40 min.
ABCDE
ABC on side; fingerstick glucose + thiamine if indicated; lorazepam 0.1 mg/kg IV (max 4 mg/dose, may repeat once) — or midazolam 10 mg IM if no access; prepare second-line immediately.
0–5 min: ABC, lateral position, O₂, suction, glucose + thiamine 100 mg if malnourished; start timer — status = ≥5 min continuous or recurrent without regaining consciousness
5–15 min — benzo: lorazepam 0.1 mg/kg IV (max 4 mg, may repeat ×1) or midazolam 10 mg IM/buccal if no IV — underdosing is the commonest error
15–30 min — load second-line: levetiracetam 60 mg/kg (max 4500 mg) OR fosphenytoin 20 mgPE/kg OR valproate 40 mg/kg — all equivalent (ESETT); give even if seizures stop after benzo
30–40 min — refractory: intubate + midazolam 0.2 mg/kg load then 0.05–2 mg/kg/h infusion, or propofol (avoid prolonged high-dose — PRIS) — target EEG suppression, not just no convulsions; ketamine is an emerging option for super-refractory status
Investigate in parallel: CT head, labs (Na, Ca, Mg, glucose, AED levels, tox), EEG within the hour — treat cause: hypoglycaemia, eclampsia (MgSO₄), meningitis (abx + aciclovir)
After control: maintain infusion 24–48 h then slow wean with EEG; load oral maintenance AED; admit to ICU
Order set
- Lorazepam 0.1 mg/kg IV (max 4 mg) ×2
- Levetiracetam 60 mg/kg (max 4500 mg)
- Thiamine 100 mg IV before dextrose
- Glucose, Na, Ca, Mg, AED levels, tox screen
- CT head once stabilised
- EEG monitoring (rule out non-convulsive SE)
- Intubation kit + midazolam infusion ready
Monitor
- ContinuousEEG if intubated/paralysed — convulsions can stop while seizures continue
- q5 minTime of each intervention — benzodiazepine at 5, second-line by 20, airway by 40
- q1 hGlucose until stable; BP with infusions
- 24–48 hSeizure-free on infusion before weaning
Escalate / ICU
- Seizure >30–40 min despite 2 agents
- Need for anaesthetic infusion
- Refractory hypoxia or rising ICP signs
- Unknown cause with normal CT — LP after exclusion of mass
Criteria
BenzoLorazepam 0.1 mg/kg — full dose, may repeat once
2nd lineLEV 60 mg/kg = fosphenytoin 20 mgPE/kg = valproate 40 mg/kg
RefractoryMidazolam or propofol infusion + EEG after 30–40 min
Wean24–48 h seizure-free, on oral maintenance, cause treated
Never
- Underdose benzodiazepines for fear of respiratory depression — intubation beats ongoing seizures
- Skip second-line loading because convulsions stopped
- Paralyse without EEG — you blind yourself to ongoing seizures
Key
- ESETT: levetiracetam = fosphenytoin = valproate (~50% each) — pick what's fastest to hand
- Midazolam 10 mg IM is the best no-IV option (faster than hunting access)
- ~20% of convulsive status becomes non-convulsive — EEG everyone who doesn't wake up
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Seizure >10 min
- Cyanosis, trauma, tongue bite with ongoing twitching
- Fever + neck stiffness (meningoencephalitis)
- Pregnancy — eclampsia until proven otherwise
Differentials
- Hypoglycaemia, hyponatraemia
- Alcohol/benzodiazepine withdrawal
- Meningitis/encephalitis
- Non-epileptic attack disorder (diagnosis of exclusion — pelvis thrust, eyes closed)
Common mistakes
- Diazepam PR delays while IV available
- Forgetting AED levels in known epileptics (subtherapeutic phenytoin)
- No cause found = no LP done
- Weaning infusion at 12 h → relapse
Disposition & follow-up
ICU until 24–48 h seizure-free; MRI + LP workup; neurology follow-up; driving advice per local law after any first seizure.
💊 Treatment detail — doses & preparation
Lorazepambenzodiazepine
DoseStatus: 0.1 mg/kg IV (max 4 mg/dose), may repeat ×1
Preparation4 mg/mL vial dilute 1:1 with NS; slow push
MonitorRR, SpO₂; flumazenil caution in chronic users
Midazolambenzodiazepine
DoseNo-IV status: 10 mg IM/buccal. Refractory: 0.2 mg/kg load then 0.05–2 mg/kg/h infusion
PreparationIM undiluted (5 mg/mL); infusion 50 mg in 50 mL NS syringe pump
MonitorRR, BP, EEG target if refractory; tachyphylaxis after days
Levetiracetamantiepileptic
DoseStatus: 60 mg/kg IV (max 4500 mg) over 15 min; maintenance 500–1500 mg BD
Preparation500 mg/5 mL vial in 100 mL NS over 15 min; PO tablets/solution 1:1 conversion
MonitorMood/behaviour changes; minimal interactions
Fosphenytoinantiepileptic
Dose20 mgPE/kg IV at 100–150 mgPE/min
PreparationDilute in 100–250 mL NS; cardiac monitor during load
MonitorBP, ECG (hypotension/arrhythmia), level 2 h post-load
Sodium valproateantiepileptic
DoseStatus: 40 mg/kg IV (max 3000 mg) at 10 mg/min; maintenance 10–15 mg/kg/day
PreparationDilute 400 mg vial per protocol over 5–10 min
MonitorLFTs, platelets, ammonia; teratogenic — avoid in pregnancy
PropofolIV anaesthetic
DoseSedation 5–50 mcg/kg/min infusion; refractory SE titrate to EEG
Preparation1% (10 mg/mL) lipid emulsion ready vial via syringe pump; change tubing q12 h
MonitorBP (vasodilates), triglycerides, PRIS if prolonged/high dose
📖 ESETT trial; textbook Ch.51Reviewed July 2026