Approach to the Critical Patient

Status epilepticus recognition and escalation

Status epilepticus triggers

Airway, breathing, and circulation

Airway priorities

Circulation and glucose

Immediate stabilization sequence

Benzodiazepine administration — first-line at 5 minutes

Second-line agents — initiate at 20 minutes if refractory

Third-line (refractory SE at 40–60 minutes)

Consultation triggers

Neurology — emergent

Intensive care

Neurosurgery

History

Seizure semiology

Ictal description

Postictal phase characterization

Onset and triggers

Timing and context

Trigger factors

Prior seizure history

Previous episodes

Medical and surgical history

Witness account and social context

Eyewitness history — most important single diagnostic element

Social and functional context

Family history

Familial epilepsy patterns

Physical Exam

Vital signs and general

Hemodynamic and oxygenation assessment

Neurologic examination

Consciousness and mental status

Focal deficits

Head, oropharynx, and skin

Head and face

Skin findings

Cardiovascular and musculoskeletal

Cardiac auscultation

Musculoskeletal

Differential Diagnosis

Life-threatening mimics

Cardiac syncope

Intracranial hemorrhage

CNS infection — meningitis or encephalitis

Eclampsia

Seizure mimics

Psychogenic nonepileptic seizure (PNES)

Vasovagal syncope

Frontal lobe seizure

Other epileptic seizure types

Focal-to-bilateral tonic-clonic seizure

Acute symptomatic seizure

Non-REM parasomnia

Laboratory Tests

Point-of-care testing

Immediate bedside glucose

Metabolic panel

Basic metabolic profile

Hematology and infection

Complete blood count

Blood cultures

C-reactive protein or procalcitonin

Targeted laboratory studies

Pregnancy test

Toxicology screen

Antiseizure medication levels

Serum lactate

Creatine kinase

Serum prolactin

Liver function tests

Lumbar puncture

Diagnostic Tests

Scoring Systems

CHESS score — risk stratification for seizure recurrence

Status epilepticus severity scoring

First seizure recurrence risk stratification

MRI

MRI brain with epilepsy protocol

CT

CT head without contrast — emergency indication

CT imaging not routinely required

Ultrasound

Bedside focused ultrasound — limited direct role in seizure workup

Disposition

Admission indications

Mandatory admission criteria

ICU admission criteria

Discharge criteria

Safe discharge requirements

Discharge documentation

Transfer criteria

Transfer indications

Transfer timing

Treatment

Acute seizure termination

Phase 1: Immediate (0–5 minutes)

Phase 2: First-line benzodiazepines (5–20 minutes)

Phase 3: Second-line agents (20–40 minutes — benzodiazepine refractory)

Phase 4: Third-line (40–60 minutes — refractory status epilepticus)

Post-seizure management

Identify and correct provoking factors

Antiseizure medication initiation decision

Antiseizure medication selection

Levetiracetam — preferred first-line for most patients

Valproate — most efficacious for idiopathic generalized epilepsy

Lamotrigine — alternative for GTC

Medications that aggravate idiopathic generalized epilepsy — avoid

Special Populations

Pregnancy

Seizure management in pregnancy

Antiseizure medication considerations in pregnancy

Labor and delivery planning

Geriatric

Epidemiology and etiology in older adults

Clinical presentation differences

Drug selection and dosing in elderly

Drug interactions

Pediatrics

Age-specific seizure considerations

Pediatric dosing for acute seizures

Pediatric chronic ASM selection

School and safety counseling

Background

Epidemiology

Incidence and prevalence

Provoked vs. unprovoked seizures

Recurrence risk after first unprovoked seizure

Mortality

Pathophysiology

Seizure initiation and propagation

Classification of GTC seizures

Consequences of prolonged seizures

Therapeutic Considerations

Evidence base for acute treatment

Evidence base for ASM initiation after first seizure

Drug resistance definition

Patient Discharge Instructions

copy discharge instructions

Diagnosis and what happened

Activity restrictions

Medication instructions

Seizure first aid for family and caregivers

Follow-up appointments

Return to emergency department immediately if

References

Guidelines and key sources

Smith PEM — Initial Management of Seizure in Adults — New England Journal of Medicine 2021

Gavvala JR, Schuele SU — New-Onset Seizure in Adults and Adolescents — JAMA 2016

Asadi-Pooya AA et al — Adult Epilepsy — Lancet 2023

Smith MD et al — ACEP Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the ED With Seizures 2024

Chamberlain JM et al — ESETT Trial — Lancet 2020

Landmark trials and society guidelines

Glauser T et al — AES Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus — Epilepsy Currents 2016

Krumholz A et al — AAN/AES Guideline: Management of an Unprovoked First Seizure in Adults — Neurology 2015

Kanner AM, Bicchi MM — Antiseizure Medications for Adults With Epilepsy — JAMA 2022

Gettings JV et al — Diagnosis and Management of Status Epilepticus — Lancet Neurology 2025

Adan G et al — Prognostic Factors Predicting Unprovoked Seizure Recurrence — Cochrane Database 2025

Sen A et al — Epilepsy in Older People — Lancet 2020

Betjemann JP, Lowenstein DH — Status Epilepticus in Adults — Lancet Neurology 2015