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
- Seizing? Give IM/IV benzodiazepine immediately; secure airway and IV access.
- Load a second-line antiseizure medication; check glucose, Na+, tox, and pregnancy.
- If refractory → intubate and start continuous anesthetic with EEG; treat cause (infection, stroke, toxins).
- Prevent complications (hyperthermia, rhabdo); plan wean after 24–48 h seizure control.
Clinical Synopsis & Reasoning
Seizure >5 minutes or recurrent seizures without recovery is status epilepticus. Give IM/IV benzodiazepines immediately, then load levetiracetam, fosphenytoin, or valproate. For refractory cases, intubate and start continuous anesthetic infusion with EEG monitoring while treating precipitants.
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 | Reversible causes | Hypoglycemia, hyponatremia | Treat immediately |
| Noncontrast head CT and labs | Etiology | Trauma, hemorrhage, infection, tox | Guide therapy |
| EEG (urgent) | Confirmation/monitoring | Nonconvulsive SE | Titrate anesthetics |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Ongoing convulsions >5 min or recurrent without recovery | True emergency | Immediate benzo + second-line; airway prep; ICU |
| Respiratory compromise or refractory SE | Hypoxia/aspiration risk | Intubate; continuous anesthetic infusion |
| Fever/meningismus, trauma, pregnancy | Alternate/precipitant | LP/CT as appropriate; treat cause |
| Hyperthermia, rhabdomyolysis, lactic acidosis | Organ failure risk | Active cooling; fluids; labs q4–6 h |
| New focal deficit or known mass | Structural cause | Neuroimaging STAT; neurosurgery consult |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Midazolam 10 mg IM (or Lorazepam 4 mg IV) | Benzodiazepine | Minutes | First-line | Repeat once if needed |
| Levetiracetam 60 mg/kg IV (max 4500 mg) or Fosphenytoin 20 mg PE/kg IV or Valproate 40 mg/kg IV | Second-line ASMs | Hours | Choose based on comorbidities | Avoid valproate in pregnancy/liver disease |
| Propofol or Midazolam infusion (refractory) | Anesthetic | Minutes | EEG burst suppression target | Monitor hypotension/PRIS |
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/AAN guidelines on status epilepticus — Link