FFinalistSouthampton · 2027
Acute care
AKT · Acute care/Neurological

Status epilepticus

Continuous/recurrent seizures ≥5 minutes

Overview

A seizure lasting ≥5 minutes, or repeated seizures without recovery between them — a neurological emergency. Managed by a timed, stepwise protocol: benzodiazepine first, then a second-line antiepileptic, then anaesthesia, while excluding hypoglycaemia and other causes.

Recognise

  • Continuous convulsive activity ≥5 min or recurrent seizures without recovery
  • ABC compromise, hypoxia, aspiration risk; later non-convulsive status (fluctuating consciousness)
  • Causes: epilepsy (missed medication), alcohol, hypoglycaemia, infection, stroke, eclampsia

Red flags

  • Ongoing seizure >5 min; refractory status; check glucose and (in pregnancy) eclampsia

Differentials & how to tell them apart

Hypoglycaemialow glucose — a reversible cause; always check
Eclampsiapregnant/postpartum + hypertension → magnesium sulfate, not standard antiepileptics
Non-epileptic attack disorderpreserved awareness/atypical features; do not over-treat
Meningitis/encephalitisfever, headache — treat infection

Investigations

Capillary glucose immediately; bloods incl. U&E/calcium/magnesium, antiepileptic levels, toxicology; imaging/EEG once stabilised.

Management

IV lorazepam (repeat once), then IV levetiracetam/phenytoin/valproate, then GA in ICU

  1. 1ABC, high-flow O2, check glucose. IV lorazepam (or buccal midazolam if no access); repeat once after 5–10 min if still fitting.Gate: Pregnant/postpartum with seizures + hypertension = ECLAMPSIA → magnesium sulfate, not the standard benzodiazepine ladder
  2. 2Still seizing: second-line IV antiepileptic (levetiracetam/phenytoin/valproate).
  3. 3Refractory: rapid-sequence induction + general anaesthesia in ICU; treat the underlying cause.
Benzodiazepine (IV lorazepam, or buccal midazolam/rectal diazepam if no access) — first-line, may repeat once after 5–10 min
Second-line: IV levetiracetam / phenytoin / sodium valproate — if seizures continue
General anaesthesia (e.g. propofol/thiopental) — refractory status — ICU/intubation

Key points

Always check glucose. In pregnancy, think eclampsia (magnesium). Don’t exceed two benzodiazepine doses before escalating (respiratory depression).

Monitor & prognosis

Seizure activity, ABC/SpO2, glucose, drug levels; EEG if non-convulsive status suspected.

Outcome worsens with duration — treat fast.

Source: NICE NG217 (epilepsies); status epilepticus protocols