FFinalistSouthampton · 2027
Neurology
AKT · Neurology/Seizures, delirium & paeds

Status epilepticus

Seizure ≥5 min or recurrent seizures without recovery

Overview

A seizure lasting ≥5 minutes, or repeated seizures without recovery between them — a neurological emergency. A timed, stepwise protocol: benzodiazepine first, then a second-line antiepileptic, then anaesthesia, while checking glucose and (in pregnancy) treating eclampsia.

Recognise

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

Red flags

  • Ongoing seizure >5 min, refractory status, hypoglycaemia, eclampsia in pregnancy

Differentials & how to tell them apart

Hypoglycaemialow glucose — reversible; always check
Eclampsiapregnant/postpartum + hypertension → magnesium sulfate, not the standard benzodiazepine ladder
Psychogenic non-epileptic statusatypical features, preserved awareness
Meningitis/encephalitisfever, treat the infection

Investigations

Capillary glucose immediately; bloods (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.Gate: Pregnant/postpartum + 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; buccal midazolam/rectal diazepam if no access) — first-line, repeat once after 5–10 min
Second-line: IV levetiracetam / phenytoin / valproate — if still seizing
General anaesthesia (propofol/thiopental) — refractory — ICU/intubation

Key points

Always check glucose. Think eclampsia in pregnancy (magnesium). Do not exceed two benzodiazepine doses before escalating (respiratory depression). (Also on the Acute Care page.)

Monitor & prognosis

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

Outcome worsens with seizure duration — treat fast.

Source: NICE NG217 (epilepsies); status epilepticus protocols