Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or immunomodulation when indicated; document follow‑up and patient education.
Algorithm
- T0–5 min: ABCs, glucose, IV access, lorazepam 0.1 mg/kg IV; repeat once in 5 min if persists.
- T5–20 min: give one second‑line ASM (levetiracetam 60 mg/kg IV, or valproate 40 mg/kg IV, or fosphenytoin 20 mg PE/kg).
- T20–40 min: if ongoing seizures → additional second‑line agent or prepare for anesthetic infusion.
- Refractory: intubate as needed; start continuous EEG and anesthetic infusion (midazolam/propofol/pentobarbital).
- Identify and treat underlying cause; plan maintenance ASM regimen.
Clinical Synopsis & Reasoning
Seizure activity ≥5 minutes (or recurrent without recovery) warrants immediate benzodiazepines followed by second‑line antiseizure medications (levetiracetam, valproate, or fosphenytoin). Refractory cases require anesthetic infusions and ICU care.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced or 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 |
|---|---|---|---|
| Fingerstick glucose | Rule out hypoglycemia | Low glucose | Correct immediately |
| Electrolytes/ABG, toxicology | Etiology | Derangements/toxins | Treat causes |
| EEG (urgent) | Ongoing seizures/NCSE | Epileptiform activity | Guide therapy |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Lorazepam 0.1 mg/kg IV (max 4 mg) | Benzodiazepine | Minutes | First‑line termination | Repeat once if needed |
| Levetiracetam 60 mg/kg IV (max 4500 mg) | ASM | Minutes | Second‑line option | Renal dosing |
| Valproate 40 mg/kg IV (max 3000 mg) | ASM | Minutes | Second‑line option | Avoid in pregnancy/liver disease |
| Fosphenytoin 20 mg PE/kg IV | ASM | Minutes | Second‑line option | Hypotension/arrhythmia risk |
| Midazolam/Propofol/Pentobarbital infusion | Anesthetics | Minutes | Refractory SE | ICU with EEG |
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
- American Epilepsy Society Guideline for Convulsive Status Epilepticus (2016) — Link