Status epilepticus

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  • Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments.[1][2] (Previous definitions used a 30-minute time limit)[3]
  • Overall mortality is high (22%)[4]

Clinical Features

  • Seizure > 20 minutes. [5]
  • Presume status in current seizure > 5 minutes[6]

Differential Diagnosis



  • Clinical diagnosis


  • Protect patient from injury
    • If possible, place patient in left lateral position to reduce risk of aspiration
    • Do not place bite block!
  • Benzodiazepine (Initial treatment of choice)[7]
    • Midazolam IM 10mg (>40kg), 5mg (13-40kg), or 0.2mg/kg[8] - may also be given IN
    • Lorazepam IV 2mg or 0.1mg/kg
    • Diazepam IV 0.15-0.2mg/kg (up to 10mg) or PR 0.2-0.5mg/kg (up to 20mg)
  • Secondary medications
    • Fosphenytoin IV 20-30mg/kg at 150mg/min (may also be given IM)
      • Contraindicated in pts w/ 2nd or 3rd degree AV block
    • Valproic acid IV 20-40mg/kg at 5mg/kg/min
    • Levetiracetam IV 60mg/kg, max 4500mg/dose
    • Phenobarbital IV 20mg/kg at 50-75mg/min (be prepared to intubate)
  • Refractory medications
    • Propofol 2-5mg/kg, then infusion of 2-10mg/kg/hr OR
    • Midazolam 0.2mg/kg, then infusion of 0.05-2mg/kg/hr OR
    • Ketamine loading dose 0.5 to 3 mg/kg, followed by infusion of 0.3 to 4 mg/kg/hr[9]
    • Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)[10]
  • Consider


  • Admit to ICU or intermediate level of monitored care depending on etiology, treatments and respiratory status

External Links

See Also


  1. Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9
  2. Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8
  3. Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.
  4. Martindale JL, Goldstein JN, Pallin DJ. Emergency department seizure epidemiology. Emerg Med Clin North Am. 2011 Feb;29(1):15-27.
  5. Brodie MJ. Status epilepticus in adults. Lancet. 1990 Sep 1; 336(8714):551-2.
  6. Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med. 1998; 338:970-976
  7. Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016; 16(1):48-61.
  8. McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582
  9. Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
  10. Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.