Status Epilepticus (SE)

Clock starts at five minutes - Early treatment is both more effective and what stops progression. Neuronal damage sets in somewhere between 20 and 60 minutes. Treat airway, breathing, circulation, and the seizure simultaneously; don't sequence them.

First-line — benzodiazepine - IV lorazepam or diazepam. Lorazepam is more effective than diazepam at both stopping the seizure and preventing recurrence, and 0.1 to 0.2 mg/kg given over several minutes usually works. Higher doses are sometimes required and there is no upper limit if the seizure persists, but monitor for hypotension and respiratory depression. No IV access: IM midazolam, buccal or intranasal midazolam, or rectal diazepam.

Underdosing is the classic error - Make sure a full benzodiazepine dose has actually gone in before you reach for a second agent. Under-treatment prolongs the episode.

Second-line - Fosphenytoin, levetiracetam, or valproic acid per the 2016 American Epilepsy Society guidelines. No evidence favors one over the others, though valproic acid carries the highest level of evidence (Level B). Phenytoin loads at 20 mg/kg IV — keep the rate under 50 mg/min or you risk arrhythmias, hypotension, and cardiac arrest, and under 25 mg/min to avoid purple glove syndrome. Fosphenytoin avoids the propylene glycol diluent and can be given IM when there is no IV.

Picking the second-line agent - Valproic acid carries known teratogenic risk (neural tube defects) and warrants caution in liver or pancreatic disease, so in a pregnant patient the choice goes elsewhere. Levetiracetam has the cleanest side-effect and interaction profile of the three but needs renal dose adjustment. Those practical differences matter more than which agent is theoretically superior. ⚠ Verify current product labeling before you commit.

Refractory SE - Advanced airway management is usually needed and blood pressure support is common. Options include propofol, pentobarbital, or a continuous benzodiazepine infusion alongside other anesthetic agents, in an ICU on continuous EEG.

Airway - Treat as a full stomach and secure it early; aspiration pneumonia, hypoventilation, and hypoxia are among the commonest complications. Respiratory depression from escalating benzodiazepines is the expected cost of treatment, not a surprise.

Paralysis hides the seizure - The moment you paralyze to intubate, motor signs vanish while cortical seizure continues. Get a stat EEG. If EEG isn't available, keep treating on the presumption that seizures are ongoing.

First labs, in order - Bedside glucose (hypoglycemia is reversible and treatable in seconds), then sodium, potassium, calcium, magnesium, BUN, creatinine, bicarbonate, CBC, antiepileptic drug levels if the patient has a known seizure disorder, tox screen, and a pregnancy test in women of childbearing age. Head CT and EEG once the patient is stable enough.

Non-convulsive SE - Seizure activity on EEG with no tonic-clonic movement. Suspect it in any patient who won't wake up after a convulsion or has unexplained persistent altered mental status; subtle signs are tonic eye deviation, nystagmoid eye movements, and facial or extremity twitching, or nothing at all. EEG is the only way to make the diagnosis.

Pregnancy - Lorazepam for emergency control in the first trimester. Levetiracetam for urgent control, since phenytoin, valproate, and phenobarbital carry known first-trimester congenital-defect risk. If eclampsia is the cause, IV magnesium sulfate is the antiepileptic of choice and delivery is the definitive treatment.

SE after ECT - A prolonged induced seizure can become status. Treat with a benzodiazepine or propofol until the seizure terminates. It is more common when theophylline has been used to lengthen the seizure.

Disposition - Every SE patient gets admitted, preferably to an ICU. Refractory cases need continuous EEG, not intermittent checks.

Status epilepticus is five minutes or more of continuous clinical or electrographic seizure activity, or recurrent seizures without recovery in between — the Neurocritical Care Society's 2012 revision of the older 30-minute definition. The driver is the same imbalance behind any seizure, excess excitation or failed GABA inhibition, but it fails to self-terminate. It may be convulsive, non-convulsive, focal motor, or myoclonic, and is called refractory when it continues despite appropriate antiepileptic drugs.

Prolonged activity is directly injurious — in vitro models show permanent neurologic damage after about 30 minutes — and the systemic price is lactic acidosis, a catecholamine surge with arrhythmia and myocardial damage, hyperthermia, hypoventilation and hypoxia, aspiration pneumonia, and pulmonary edema. Mortality is 16% to 20% after a first episode of generalized convulsive SE and 35% to 60% once it becomes refractory.