A 24-year-old known epileptic is brought to A&E generalised tonic-clonic seizing. Bystanders say it has been continuous for "a while." On arrival: still convulsing, cyanotic lips, GCS unassessable.
Vitals: HR 130, SpO2 88% on room air, BP 150/95, glucose unknown, temp 37.9°C.
It is now 6 minutes since the seizure was first witnessed and it has not stopped. What do you do — in order?
Defining Status Epilepticus
Status epilepticus (SE) is no longer defined by a fixed time cut-off alone — it is defined by the point at which a seizure is unlikely to self-terminate and ongoing seizure activity risks long-term neuronal injury. For generalised convulsive seizures, that operational point is now widely accepted as 5 minutes of continuous seizure activity, or two or more seizures without full recovery of consciousness between them.
This 5-minute threshold matters clinically: it means you should be pulling out the emergency drug protocol well before the "classic" 30-minute definition some older textbooks still use. Treat early — don't wait to see if it stops on its own.
T1 (5 minutes): the point at which treatment should start — seizure unlikely to stop spontaneously.
T2 (30 minutes): the point at which ongoing seizure activity risks long-term neuronal injury, cardiorespiratory compromise, and worse outcome. Your entire drug algorithm needs to be complete by T2.
Immediate Actions — Before Any Drug
ABC First, Always
- Airway: Position semi-prone/recovery if possible, do not force anything into the mouth, prepare for airway adjunct if post-ictal obstruction
- Breathing: High-flow oxygen, pulse oximetry, watch for hypoventilation especially after benzodiazepines
- Circulation: IV access (two lines if possible), send bloods: glucose, U&E, calcium, magnesium, FBC, anticonvulsant levels if on treatment, toxicology if indicated
- Don't forget glucose: Check capillary glucose immediately — if <3mmol/L, give IV glucose (or IM glucagon if no access) before or alongside first-line treatment. Hypoglycaemic seizures won't stop with benzodiazepines alone.
- Time it: Note the exact time the seizure started — every subsequent drug decision is timed from this point
The Drug Algorithm — Timed
| Time | Step | Drug & Dose |
|---|---|---|
| 0–5 min | Stabilise | ABC, oxygen, IV access, glucose check, bloods |
| 5 min (First-line) | Benzodiazepine | IV lorazepam 4mg (or IV/PR diazepam 10mg, or buccal/IM midazolam 10mg if no IV access) — repeat once after 5–10 min if seizure continues |
| 20–25 min (Second-line) | IV loading agent | IV levetiracetam 60mg/kg (max 4.5g), or phenytoin 20mg/kg (with cardiac monitoring — risk of arrhythmia/hypotension), or sodium valproate 40mg/kg |
| 40–45 min (Refractory) | Established status | Seizure persisting despite two drug classes = refractory status epilepticus. Call for senior/ICU help now if not already involved. |
| 45–60 min (Third-line) | General anaesthesia | RSI with propofol or thiopental, ICU admission, continuous EEG monitoring if available |
Giving repeated doses of benzodiazepines beyond the second dose without escalating to a second-line agent. This delays effective treatment and increases the risk of respiratory depression without controlling the seizure — know your algorithm and move to the next step on time, not "just one more dose."
Finding the Cause
Treating the seizure is only half the job — status epilepticus is a presentation, not a diagnosis. In a known epileptic, think about missed medication doses, intercurrent infection, sleep deprivation, or alcohol withdrawal. In a first presentation, the differential is much broader and more urgent to pin down.
Causes to Actively Exclude
- Metabolic: Hypoglycaemia, hyponatraemia, hypocalcaemia, uraemia, hepatic encephalopathy
- Infective: Meningitis, encephalitis, cerebral malaria, sepsis with fever
- Structural: Stroke, tumour, subdural/subarachnoid haemorrhage, cerebral abscess
- Toxic/withdrawal: Alcohol withdrawal, drug toxicity, eclampsia in pregnancy
- Non-adherence: Missed or subtherapeutic antiepileptic drug levels — the most common cause in known epileptics
A CT head is indicated in any first-presentation status, any focal neurological signs, head trauma, fever, or failure to return to baseline consciousness after seizures stop. A lumbar puncture should be considered if infection is suspected, once raised ICP has been excluded.
Non-Convulsive Status — Don't Miss It
Not all status epilepticus convulses. Non-convulsive status epilepticus (NCSE) should be suspected in any patient with unexplained, persistently reduced consciousness — especially after a convulsive seizure has "stopped" clinically but the patient never wakes up. The only way to confirm it is EEG. If available, get one; if not, a trial of IV benzodiazepine with clinical improvement is diagnostic.
Glucose was 2.1mmol/L — IV 10% dextrose given immediately alongside IV lorazepam 4mg. Seizure terminated within 90 seconds of the dextrose bolus. Post-ictal GCS improved to 14 over 10 minutes. Review of the patient's medication chart revealed she had not eaten in over 24 hours after running out of food, and had taken her usual insulin regardless — a hypoglycaemic seizure, not primary epilepsy breakthrough. This case is a reminder: always check glucose before assuming the seizure is "just" epilepsy.
Treat from 5 minutes, not 30. ABC and glucose come before or alongside your first drug. First-line = benzodiazepine, second-line = IV loading agent (levetiracetam/phenytoin/valproate), third-line = general anaesthesia and ICU. Refractory status needs senior help early, not late. Always look for the underlying cause — status is a symptom.
References
- Glauser T et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults. Epilepsy Currents. 2016;16(1):48–61.
- Trinka E et al. A definition and classification of status epilepticus — ILAE Task Force Report. Epilepsia. 2015;56(10):1515–1523.
- Kapur J et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus (ESETT). NEJM. 2019;381(22):2103–2113.
