Status epilepticusMANAGEMENT

NEUROLOGICAL PRESENTATIONS · 12 SECTIONS

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656 items

☷ Legend

01Approach to the Critical Patient/attcp74

Immediate stabilization

›Initial priorities

›Airway risk

›Ongoing convulsions

›Inability to protect airway

›Persistent hypoxemia

›Recurrent emesis

›Breathing support

›High flow oxygen

›End tidal CO2 if available

›Bag valve mask ventilation if apnea

›Circulation support

›Cardiac monitor

›Two large bore IV or IO

›Hypotension management

›Isotonic crystalloid bolus 20 mL/kg

›Vasopressor if shock persists

›Immediate bedside checks

›Point of care glucose

›Core temperature

›Pregnancy test if relevant

›Status definition and timing

›Operational definition

›T1 threshold for convulsive SE 5 minutes

›T2 threshold for neuronal injury risk 30 minutes

›Time zero

›Witnessed onset time

›Last known well time

›Early escalation

›Resuscitation bay criteria

›Ongoing generalized convulsions beyond 5 minutes

›Recurrent seizures without baseline recovery

›Airway compromise

›Team activation

›ICU early notification for refractory course

›Neurology early notification if available

›Anesthesia notification if intubation likely

Monitoring and access

›Monitoring bundle

›Vital sign frequency

›Every 5 minutes during active management

›Continuous pulse oximetry

›Blood pressure strategy

›NIBP cycling every 2 to 3 minutes

›Arterial line if vasopressors or anesthetic infusion

›Temperature strategy

›Active warming if hypothermia

›Active cooling if hyperthermia

›Vascular access

›IV access

›Two peripheral lines preferred

›Ultrasound guided peripheral if difficult access

›IO access

›If no IV within 2 minutes

›Medication compatibility check for IO route

Immediate treatable causes

›Reversible causes

›Hypoglycemia

›Dextrose therapy if low glucose

›Thiamine before dextrose if malnutrition risk

›Electrolyte derangements

›Sodium disorders

›Calcium disorders

›Magnesium disorders

›Toxicologic causes

›Isoniazid concern

›Bupropion concern

›Tramadol concern

›Sympathomimetic toxicity concern

›CNS infection concern

›Fever

›Neck stiffness

›Immunocompromised status

›Eclampsia concern

›Pregnancy beyond 20 weeks

›Severe hypertension

›Headache or visual symptoms

02History/hx66

Key history elements

›Core seizure history

›Prior epilepsy

›Baseline seizure type and frequency

›Typical duration

›Current event timeline

›Time of onset

›Continuous convulsions vs intermittent

›Recovery between events

›Semiologic clues

›Focal onset features

›Generalized onset features

›Eye deviation

›Cyanosis

›Postictal course

›Return to baseline

›Persistent confusion duration

›Medication and adherence

›Antiseizure medications

›Names and doses

›Last dose time

›Missed doses

›Recent medication changes

›Dose reduction

›New interacting drugs

›Benzodiazepine exposure

›Home rescue meds

›EMS meds and times

›Provoking factors

›Infection symptoms

›Fever

›Respiratory symptoms

›GI symptoms

›Sleep deprivation

›Night shift

›Insomnia

›Substance use

›Alcohol withdrawal risk

›Stimulant use

›Cannabis concentrates

›Metabolic stressors

›Vomiting

›Diarrhea

›Poor intake

›Pregnancy related

›Gestational age

›Preeclampsia symptoms

›Structural and vascular risk

›Head trauma

›Recent fall

›Anticoagulant use

›Stroke risk

›Atrial fibrillation

›Recent focal deficits

›Brain tumor history

›Known lesions

›New headaches

PITFALLS

›Common misses

›Pseudoseizure concern

›Do not delay benzodiazepines if ongoing convulsions and unstable

›Early EEG for diagnostic uncertainty if stable

›Nonconvulsive status after convulsive cessation

›Persistent altered mental status

›Subtle motor signs

›Medication underdosing

›Weight based benzodiazepine dose errors

›Inadequate second line load

03Physical Exam/exam45

Focused exam during stabilization

›Neurologic domains

›Level of consciousness

›GCS trend

›Persistent unresponsiveness

›Pupils

›Size and reactivity

›Asymmetry

›Motor findings

›Ongoing rhythmic activity

›Focal weakness after event

›Asymmetric tone

›Brainstem signs

›Gag reflex status

›Corneal reflex status

›Respiratory and airway

›Work of breathing

›Apnea episodes

›Aspiration signs

›Oxygenation

›SpO2 trend

›Cyanosis

›Cardiovascular and perfusion

›Hemodynamics

›Hypotension

›Severe hypertension

›Perfusion

›Capillary refill

›Skin temperature

›Trauma screen

›Head and face injuries

›Tongue bite

›Scalp hematoma

›Musculoskeletal injuries

›Shoulder dislocation concern

›Vertebral tenderness

PEARLS

›Exam interpretation

›Focal deficits

›Consider stroke

›Consider intracranial hemorrhage

›Persistent coma after cessation

›Consider nonconvulsive status

›Consider sedative effect

›Consider hypoxic injury

›Severe hypertension with pregnancy

›Eclampsia until proven otherwise

04Differential Diagnosis/ddx39

Life threatening causes

›High risk diagnoses

›CNS hemorrhage

›Intracerebral hemorrhage

›Subarachnoid hemorrhage

›Ischemic stroke with seizure

›Large vessel occlusion

›Cortical infarct

›CNS infection

›Meningitis

›Encephalitis

›Toxicologic

›Isoniazid toxicity

›Tricyclic antidepressant toxicity

›Organophosphate toxicity

›Metabolic

›Hypoglycemia

›Hyponatremia

›Hypocalcemia

›Uremia

›Eclampsia

›Generalized tonic clonic seizure in pregnancy

›Severe hypertension

Mimics and related entities

›Alternative explanations

›Psychogenic nonepileptic seizures

›Prolonged fluctuating course

›Asynchronous movements

›Syncope with myoclonus

›Prodrome

›Rapid recovery

›Rigors

›Febrile illness context

›Movement disorders

›Dystonia

›Chorea

Coding anchors

›Standardized coding

›ICD-10 G40.901 status epilepticus unspecified not intractable

›ICD-10 G41.9 status epilepticus unspecified

›SNOMED CT concept status epilepticus

›SNOMED CT concept nonconvulsive status epilepticus

05Laboratory Tests/lt56

Immediate point of care

›Bedside tests

›Point of care glucose

›Hypoglycemia threshold local protocol

›Repeat after treatment

›Venous blood gas

›pH trend

›PCO2 mmHg for hypoventilation

›Lactate mmol/L

›Postictal elevation expected

›Persistent rise suggests ongoing seizure or shock

Core bloodwork

›Baseline labs

›Electrolytes

›Sodium mmol/L

›Potassium mmol/L

›Chloride mmol/L

›Bicarbonate mmol/L

›Renal function

›Urea mmol/L

›Creatinine umol/L local units

›Calcium panel

›Ionized calcium mmol/L if available

›Magnesium mmol/L

›Phosphate mmol/L

›CBC

›Infection clue

›Anemia clue

›Liver enzymes

›Hepatic injury clue

›Valproate planning context

›Directed labs

›Antiseizure drug levels when applicable

›Phenytoin total level

›Valproate level

›Carbamazepine level

›Toxicology

›Acetaminophen level if overdose concern

›Salicylate level if overdose concern

›Ethanol level if withdrawal planning

›CK

›Rhabdomyolysis screening after prolonged convulsions

›Troponin if chest pain or arrhythmia

›Seizure related elevation possible

›ACS differentiation as needed

Infectious workup triggers

›Infection evaluation

›Blood cultures

›Fever

›Hemodynamic instability

›Urinalysis and culture

›Older adults

›Pregnancy

›Lumbar puncture labs set

›CSF cell count

›CSF protein

›CSF glucose

›CSF Gram stain and culture

›CSF HSV PCR when indicated

06Diagnostic Tests/dt69

Scoring Systems

›Classification and risk tools

›Status subtype classification

›Convulsive status epilepticus

›Nonconvulsive status epilepticus

›Refractory status epilepticus

›Super refractory status epilepticus

›Etiology framework

›Acute symptomatic

›Remote symptomatic

›Progressive symptomatic

›Unknown

›Prognostic scores

›STESS use in ICU planning

›EMSE use in ICU planning

›Limitation for ED decision making

›Not validated for discharge decisions

MRI

›MRI brain

›Indications

›New focal deficits with negative CT

›Suspected encephalitis

›Suspected tumor

›Sequences

›DWI for acute infarct

›FLAIR for edema

›Contrast when mass or infection suspected

›Limitations

›Time to acquisition

›Need for airway control

›Motion artifact risk

›CT head without contrast

›Indications

›First seizure with persistent altered mental status

›Focal neurologic deficit

›Head trauma

›Immunocompromised state

›Anticoagulation

›Findings

›Intracranial hemorrhage

›Mass effect

›Hydrocephalus

›Timing principle

›Do not delay benzodiazepines for CT

›CT angiography head and neck

›Indications

›Suspected large vessel occlusion

›Thunderclap headache with SAH concern after noncontrast CT pathway

›Limitations

›Contrast allergy

›Renal risk assessment

Ultrasound (or US)

›Point of care ultrasound

›Airway and ventilation adjuncts

›Lung ultrasound for aspiration pattern

›Diaphragm motion if paralysis concern

›Hemodynamic adjuncts

›IVC assessment for volume status support

›Cardiac views for tamponade if arrest

›Pregnancy adjuncts

›Intrauterine pregnancy confirmation if unstable

EEG

›Electroencephalography

›Indications

›Persistent altered mental status after convulsions stop

›Suspected nonconvulsive status epilepticus

›Paralyzed and sedated patient

›Timing

›As soon as feasible for suspected NCSE

›Continuous EEG for refractory status

›Interpretation pearls

›Electroclinical dissociation risk after neuromuscular blockade

›Periodic discharges and ictal patterns need expert review

07Disposition/dispo29

Level of care

›Admission criteria

›Any status epilepticus episode

›ICU if refractory or intubated

›Stepdown if controlled but high recurrence risk

›ICU criteria

›Need for mechanical ventilation

›Continuous anesthetic infusion

›Vasopressors

›Continuous EEG requirement

›Ward criteria

›Fully awake baseline recovery

›Clear reversible trigger corrected

›Neurology plan in place

›Transfer criteria

›Need for continuous EEG not available

›Refractory status requiring anesthesia support

›Suspected encephalitis needing specialty care

Discharge considerations

›Rare discharge pathway

›Not status epilepticus after reassessment

›Single brief seizure with full recovery

›Normal neurologic exam

›Safety prerequisites

›Reliable supervision

›Return precautions understood

›Follow up arranged

›Driving and activity restrictions

›Jurisdiction specific guidance

›Avoid swimming alone

›Avoid heights and machinery

08Treatment/t179

First line benzodiazepines

›Benzodiazepine strategy

›Time based trigger

›If convulsions at 5 minutes start benzodiazepine

›If active convulsions after first dose repeat once

›Preferred routes

›IV if access established

›IM if no IV

›IN or buccal if no IV and IM delayed

›Lorazepam IV

›Adult dosing

›0.1 mg/kg IV

›Maximum single dose 4 mg

›Repeat once after 5 minutes if ongoing

›Pediatric dosing

›0.1 mg/kg IV

›Maximum single dose 4 mg

›Repeat once after 5 minutes if ongoing

›Midazolam IM

›Adult dosing

›10 mg IM single dose

›Consider 0.2 mg/kg IM if weight based approach

›Pediatric dosing

›0.2 mg/kg IM

›Maximum 10 mg

›Midazolam IN or buccal

›Pediatric dosing

›0.2 mg/kg

›Maximum 10 mg

›Adult dosing

›5 mg per nostril typical dosing pathway

›Local protocol alignment

›Diazepam IV

›Adult dosing

›0.15 to 0.2 mg/kg IV

›Maximum single dose 10 mg

›Repeat once after 5 minutes if ongoing

›Pediatric dosing

›0.2 mg/kg IV

›Maximum single dose 10 mg

Second line antiseizure loading

›Escalation trigger

›If seizures persist 10 to 20 minutes after benzodiazepines start second line load

›If recurrent seizures without recovery start second line load

›Levetiracetam IV

›Loading

›60 mg/kg IV

›Maximum 4500 mg

›Infusion time 10 to 15 minutes

›Advantages

›Minimal hemodynamic effect

›Few drug interactions

›Valproate IV

›Loading

›20 to 40 mg/kg IV

›Maximum 3000 mg

›Infusion time 10 to 15 minutes

›Avoidance

›Pregnancy

›Severe hepatic disease

›Known urea cycle disorder

›Fosphenytoin IV

›Loading

›20 mg PE/kg IV

›Maximum 1500 mg PE

›Infusion rate up to 150 mg PE per minute

›Precautions

›Arrhythmia risk

›Hypotension risk

›Narrow complex tachyarrhythmias concern

›Phenytoin IV

›Loading

›20 mg/kg IV

›Infusion rate up to 50 mg per minute

›Precautions

›Hypotension risk

›Arrhythmia risk

›Tissue injury risk with extravasation

›Phenobarbital IV

›Loading

›20 mg/kg IV

›Additional 5 to 10 mg/kg if needed

›Use cases

›Alcohol withdrawal refractory to benzodiazepines

›Neonates and infants per protocol

›Monitoring

›Respiratory depression risk

›Hypotension risk

Refractory status and anesthetic infusions

›Refractory definition

›Ongoing seizures after adequate benzodiazepine

›Ongoing seizures after adequate second line load

›Airway and ventilation

›Intubation triggers

›Persistent convulsions despite meds

›Need for anesthetic infusion

›Recurrent apnea

›RSI considerations

›Avoid long acting paralysis without EEG plan

›Post intubation sedation plan before paralysis

›Continuous infusion goals

›EEG targets

›Seizure suppression

›Burst suppression target per neurology plan

›Hemodynamic targets

›Maintain MAP per age and comorbidity

›Vasopressor support readiness

›Midazolam infusion

›Bolus

›0.2 mg/kg IV

›Repeat bolus 0.1 mg/kg if needed

›Infusion start

›0.05 to 0.2 mg/kg per hour

›Titration

›Increase 0.05 to 0.1 mg/kg per hour every 5 to 15 minutes

›Typical upper range 2 mg/kg per hour

›Adverse effects

›Hypotension

›Tachyphylaxis

›Propofol infusion

›Bolus

›1 to 2 mg/kg IV

›Infusion start

›20 microg/kg per minute

›Titration

›Increase 5 to 10 microg/kg per minute every 5 minutes to suppression

›Typical range 20 to 80 microg/kg per minute

›Adverse effects

›Hypotension

›Hypertriglyceridemia

›Propofol infusion syndrome risk

›Ketamine infusion

›Bolus

›1 to 2 mg/kg IV

›Infusion start

›0.5 to 1 mg/kg per hour

›Titration

›Increase 0.5 mg/kg per hour every 10 to 20 minutes

›Typical range 1 to 5 mg/kg per hour

›Advantages

›Less hypotension than GABA agents in some patients

›Useful in super refractory status

›Barbiturate coma option

›Pentobarbital infusion

›ICU only with continuous EEG

›Profound hypotension risk

›Immunosuppression and ileus risk

Etiology specific therapies

›Hypoglycemia

›Dextrose

›Adult 25 g IV dextrose

›Pediatric 0.5 g/kg IV dextrose

›Thiamine

›100 mg IV if malnutrition risk

›Eclampsia

›Magnesium sulfate

›4 to 6 g IV loading over 15 to 20 minutes

›Maintenance 1 to 2 g per hour

›Repeat 2 g bolus for recurrent seizure

›Blood pressure management

›Severe range pathway per obstetric protocol

›Isoniazid toxicity

›Pyridoxine

›Gram for gram replacement of isoniazid if known dose

›If unknown dose 5 g IV adult

›Pediatric 70 mg/kg IV maximum 5 g

›Alcohol withdrawal

›Benzodiazepines

›High dose symptom triggered approach

›Early phenobarbital pathway where used

›Thiamine

›100 mg IV before glucose containing fluids when possible

Evidence and guideline notes

›Evidence grading

›Benzodiazepines first line for convulsive status epilepticus

›Class I recommendation in multiple society guidelines

›Second line options

›Levetiracetam

›Valproate

›Fosphenytoin

›Similar seizure cessation efficacy in comparative trials

›ACEP evidence language when referenced locally

›ACEP Level B support for early benzodiazepine therapy in prolonged seizures

›ACEP Level C support for early EEG when persistent altered mental status suggests NCSE

09Special Populations/sp32

Pregnancy

›Pregnancy specific priorities

›Eclampsia pathway

›Magnesium sulfate as first line antiseizure for eclampsia

›Obstetrics involvement early

›Medication safety

›Avoid valproate when alternatives available

›Benzodiazepines acceptable for maternal stabilization

›Imaging considerations

›CT head acceptable when indicated

›MRI preferred when feasible for nonemergent etiologies

Geriatric

›Older adult considerations

›Etiology profile

›Stroke and hemorrhage higher prevalence

›Polypharmacy interactions

›Medication sensitivity

›Higher respiratory depression risk with benzodiazepines

›Lower starting infusion rates for sedatives when used

›Disposition bias

›Lower threshold for admission and EEG

Pediatrics

›Pediatric specific approach

›Weight based dosing accuracy

›Use kg weight actual or estimated

›Dose caps applied to avoid adult overdose

›Febrile seizure differentiation

›Simple febrile seizure does not equal status

›Complex febrile seizure may require broader workup

›Airway strategy

›Earlier desaturation risk

›BVM proficiency emphasis

›Etiology clues

›Ingestion risk

›CNS infection risk by age

10Background/b30

Epidemiology

›Epidemiologic facts

›Incidence

›Status epilepticus annual incidence commonly reported 10 to 40 per 100000

›Mortality

›Higher mortality with acute symptomatic etiologies

›Higher mortality with refractory status

›Age distribution

›Bimodal peaks in young children and older adults

Pathophysiology

›Mechanisms

›Time dependent receptor trafficking

›Reduced GABA A receptor responsiveness over time

›Increased excitatory transmission over time

›Systemic consequences

›Hyperthermia risk

›Acidosis and hypercapnia risk

›Rhabdomyolysis risk

›Aspiration risk

Therapeutic Considerations

›Treatment principles

›Time sensitive benzodiazepines

›Earlier administration linked to higher seizure termination

›Delays increase refractory risk

›Loading dose sufficiency

›Underloading increases recurrence

›Timely transition to second line reduces total benzodiazepine exposure

›Continuous EEG role

›Detect nonconvulsive seizures

›Guide anesthetic titration

›Hemodynamic tradeoffs

›Sedative infusions often require vasopressors

›Ketamine may preserve blood pressure relative to others

11Patient Discharge Instructions/pdi25

copy discharge instructions

›Discharge instructions set

›Return now criteria

›Another seizure

›Seizure lasting longer than 5 minutes

›Trouble breathing

›Blue lips or persistent low oxygen

›Severe headache

›New weakness or numbness

›Fever with confusion

›Pregnancy with headache or vision changes

›Safety

›No driving until cleared by clinician per local law

›No swimming alone

›No baths unsupervised

›Avoid heights and power tools

›Medication adherence

›Take antiseizure meds exactly as prescribed

›No sudden stopping of antiseizure meds

›Triggers

›Sleep regularity

›Avoid alcohol binges

›Avoid missed meals and dehydration

›Follow up

›Neurology or primary care follow up within 1 to 2 weeks

›EEG and MRI scheduling if ordered

12References/r12

Clinical guidelines and evidence sources

›Reference set

›American Epilepsy Society guideline for convulsive status epilepticus

›Benzodiazepines first line

›Levetiracetam valproate fosphenytoin as second line options

›Neurocritical Care Society guidance for refractory status epilepticus

›Continuous EEG in refractory status

›Anesthetic infusions for seizure suppression

›Comparative trial evidence for second line agents

›Similar efficacy of levetiracetam fosphenytoin valproate in established status epilepticus

›ACEP evidence language integration

›ACEP Level B and C style statements used where local pathways reference ACEP grading

›Source file

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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