Status Epilepticus

complete reference · timed treatment algorithm · ESETT-guided 2nd line · refractory anesthesia · NCSE · Full Card

Symptoms / Associated Sx

• Definition: ≥5 minutes of continuous clinical/electrographic seizure activity, or ≥2 seizures without full recovery of consciousness between them (the operational 5-minute threshold replaces the old 30-minute definition — treat early, neurons die). Convulsive SE is overt; non-convulsive SE (NCSE) may show only subtle twitching, nystagmus, or simply a persistently altered/comatose patient with ongoing seizures on EEG.

• Breakthrough seizure in known epilepsy most often reflects subtherapeutic drug levels (missed doses, illness, drug interactions) — and can progress to SE.

Neg

• Pt does not regain full consciousness between events — confirms SE rather than discrete recurrent seizures (if they recover fully between, treat the underlying epilepsy but it is not status)

• Movements are not asynchronous/side-to-side with closed eyes and a normal EEG — argues against psychogenic status (pseudostatus) (important: don't escalate to intubation and anesthetics for PNES; EEG settles it)

• Not decerebrate/decorticate posturing from herniation (structural/ICP emergency, not ictal — different pathway)

• Not rigors or shivering with retained awareness (no impairment of consciousness)

Social History (SHx)

• Known epilepsy and AED adherence (the leading cause of breakthrough SE is missed medication); recent illness, infection, or new interacting drug.

• Alcohol and sedative use/withdrawal; illicit stimulants; sleep deprivation.

Main Etiology

• Low AED levels/non-adherence (commonest in patients with established epilepsy). Acute symptomatic causes — stroke, intracerebral hemorrhage, CNS infection (meningitis/encephalitis), traumatic brain injury, hypoxic-ischemic injury, brain tumor. Metabolic — hypo/hyperglycemia, hyponatremia, hypocalcemia, uremia, hepatic failure. Toxic — drug toxicity or alcohol/benzodiazepine withdrawal. Autoimmune/paraneoplastic encephalitis (consider in cryptogenic refractory SE).

RF

• Modifiable: AED non-adherence, alcohol/drug use, sleep deprivation, interacting medications.

• Non-modifiable: prior status epilepticus, structural/symptomatic epilepsy, acute brain injury.

Data

• POC glucose and electrolytes (Na, Ca, Mg) (immediate, correctable provokers — do not wait for the algorithm)

• AED serum levels (subtherapeutic level confirms non-adherence as the driver of a breakthrough)

• CBC, BUN/Cr, LFTs, toxicology, β-hCG, ABG (metabolic causes, intoxication, lactic acidosis from prolonged convulsion)

• CT then MRI brain (structural cause once stabilized)

• Continuous EEG (confirms seizure termination, and crucially detects ongoing non-convulsive status after visible convulsions stop — up to ~20% remain in electrographic SE)

• Lumbar puncture if infection suspected; autoimmune/paraneoplastic antibodies if cryptogenic and refractory.

DDx

Psychogenic status / pseudostatus (asynchronous movements, eye closure, normal EEG — avoid intubating) · serial discrete seizures with recovery (not SE by definition) · posturing from herniation (structural/ICP, not ictal) · severe metabolic encephalopathy with myoclonus (diffuse, treat derangement) · rigors/shivering (awareness preserved) · prolonged post-ictal state (EEG distinguishes from NCSE)

Home Meds

• Resume and reload the home AED to therapeutic levels (the loading agent can often be the patient's own drug).

• Reconcile proconvulsant or interacting medications; treat withdrawal states.

Plan

Consults

• Neurology — emergent; guides 2nd/3rd-line therapy and EEG.

• ICU / anesthesia — for refractory SE requiring continuous anesthetic infusions and airway management.

• Continuous EEG / neurodiagnostics — to confirm cessation and detect NCSE.

Timed algorithm

• 0–5 min (stabilize): airway/breathing/circulation, high-flow O2, IV access, POC glucose — if low give D50 (with thiamine 100–500 mg IV first if alcohol/malnutrition), draw labs and AED levels, place on monitor.

• 5–20 min (first-line BENZODIAZEPINE — full weight-based dose): lorazepam (Ativan) 0.1 mg/kg IV, max 4 mg per dose, may repeat once · OR if no IV: midazolam (Versed) 10 mg IM (≥40 kg) · OR diazepam (Valium) 0.15–0.2 mg/kg IV (max 10 mg). Underdosing benzodiazepines is the single most common and consequential error.

• 20–40 min (second-line AED load — choose one): levetiracetam (Keppra) 60 mg/kg IV (max 4.5 g) · OR fosphenytoin (Cerebyx) 20 mg PE/kg IV · OR valproate (Depacon) 40 mg/kg IV. ESETT trial: all three are roughly equivalent in efficacy and safety — pick by patient factors (avoid valproate in pregnancy/hepatic disease; fosphenytoin causes hypotension/arrhythmia and can't be used in some cardiac patients; levetiracetam is the easiest default).

• 40–60 min (refractory SE → anesthesia, intubate, ICU): continuous infusion — midazolam (Versed) gtt, propofol (Diprivan) gtt, or pentobarbital; titrate to seizure cessation or burst-suppression on EEG. Intubation required. This is ICU care.

• Super-refractory (>24h or recurs on weaning anesthesia): prolonged anesthetic therapy, add/optimize maintenance AEDs, treat autoimmune causes empirically, consider ketamine, ketogenic diet — neurology/ICU directed.

Parallel

• Identify and treat the cause concurrently with stopping the seizure — they are not sequential. Maintain a definitive maintenance AED once acute control is achieved (load the patient's home drug to therapeutic).

Always

• PT / OT eval after recovery; assess for injury sustained during convulsions.

• Trend: continuous EEG until seizure-free (and to exclude NCSE); AED levels; electrolytes/glucose; CK and renal function (rhabdomyolysis from prolonged convulsion); temperature; ABG/lactate.

• Escalation triggers: failure to stop after benzodiazepine + one second-line AED → refractory SE, anesthetic infusion + ICU · ongoing electrographic seizures despite no visible convulsions → NCSE, ICU · airway compromise/aspiration → intubate · hyperthermia/rhabdomyolysis/acidosis → aggressive supportive care.

• Discharge checklist: optimized maintenance AED with adherence plan and level monitoring · address the precipitant (adherence counseling, pillbox, refills; treat infection/withdrawal) · driving restriction per state law · neurology follow-up · medication-interaction review · seizure first-aid education · return precautions.

Red Flags — ICU

• Refractory SE (continues after benzo + one second-line agent) → continuous anesthetic, intubation, ICU.
• Non-convulsive status — comatose/altered patient not waking after convulsions stop → continuous EEG; it is still status.
• Airway compromise / aspiration / hypoxia → intubate.
• Hyperthermia, rhabdomyolysis, lactic acidosis from prolonged convulsion → aggressive supportive care, watch renal function.
• Super-refractory SE (>24h or recurs on anesthetic wean) → escalate, hunt autoimmune/paraneoplastic causes.

Senior IM Resident Pearls

• Five minutes, not thirty. The operational definition is ≥5 minutes — start treatment immediately; the old 30-minute definition delayed care and cost neurons.
• Give the FULL benzo dose. The commonest reason SE doesn't break is underdosing the benzodiazepine — lorazepam 0.1 mg/kg (up to 4 mg) and repeat it. Fear of respiratory depression leads to undertreatment that prolongs the seizure.
• ESETT settled the second-line debate: levetiracetam, fosphenytoin, and valproate are essentially equivalent. Pick by patient factors and give a real loading dose — don't dither over which one.
• If they don't wake up, they may still be seizing. Up to ~1 in 5 have ongoing non-convulsive status after the convulsions stop — get continuous EEG.
• Treat the cause in parallel, not after. Glucose, sodium, AED levels, imaging, and infection workup happen while you're aborting the seizure.
• Breakthrough usually means missed meds. The subtherapeutic level is the diagnosis — reload and fix adherence.
• Thiamine before dextrose in the alcohol-dependent/malnourished patient.
• Common mistake: intubating and snowing a patient with psychogenic pseudostatus. If movements are asynchronous with closed eyes and the EEG is clean, stop escalating.