Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Administer benzodiazepine immediately; secure airway and IV access.
- Start second-line antiseizure medication; investigate causes.
- If refractory → intubate and start anesthetic infusion with continuous EEG; treat precipitant.
Clinical Synopsis & Reasoning
Seizures >5 minutes or recurrent without recovery require protocolized treatment. Give benzodiazepines promptly (IM midazolam or IV lorazepam), followed by a weight-based second-line agent (levetiracetam/valproate/fosphenytoin). Refractory cases require intubation and anesthetic infusions with continuous EEG.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Point-of-care glucose and electrolytes | Rule immediate causes | Hypoglycemia, Na+, Ca2+ | Correct quickly |
| CT head (first-time focal or trauma) and EEG | Etiology/monitoring | Structural lesions; nonconvulsive status | — |
| LP/infectious workup as indicated | Cause | Meningitis/encephalitis | Start empiric therapy if suspected |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| >5 minutes continuous seizure or recurrent without recovery | Neurologic emergency | Activate protocol; escalating benzodiazepines then second-line |
| Refractory after benzos and a second agent | Ongoing neuronal injury | Intubate; anesthetic infusion; continuous EEG |
| Focal deficits, trauma, or infection signs | Structural cause | Neuroimaging; LP when safe |
| Metabolic derangements (Na, Ca, glucose) | Provoking factor | Correct immediately |
| Pregnancy (eclampsia) | Maternal-fetal risk | Magnesium sulfate; OB consult |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Midazolam 10 mg IM (or Lorazepam 0.1 mg/kg IV) | First-line | Minutes | Terminate seizures | Repeat once if needed |
| Levetiracetam 60 mg/kg IV (max 4500 mg) or Valproate 40 mg/kg or Fosphenytoin 20 mg PE/kg | Second-line | Minutes | Prevent recurrence | Contraindication-aware choices |
| Propofol/Midazolam infusions (refractory) | Anesthetic | Minutes | Burst suppression on EEG | ICU monitoring |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- Neurocritical Care Society status epilepticus guideline — Link