Status Epilepticus

Quick links · seizure types & pathways
Seizure overviewStatus EpilepticusEclampsia (pregnancy)OB EmergenciesAlcohol withdrawalToxic ingestionFebrile seizure (peds)Hypoglycemia
Seizure ≥ 5 min OR ≥ 2 without recovery
Definition

Treat by 5 min — neuronal injury and pharmacoresistance increase rapidly. Refractory if seizing after benzo + one second-line agent.

⬇ Jump to first-line benzodiazepines
Reference algorithm · tap to zoom

Source: fprmed.com — tap image to open full-screen, pinch / scroll to zoom.

≈ 154.3 lb
Weight-based doses (auto-calculated)
Glucose (if FSBG < 60)
D50 (adult)
25 g IV
D10 (peds, 5 mL/kg)
350 mL
First-line benzos (full dose, repeat ×1)
Lorazepam 0.1 mg/kg IV
max 4 mg
4 mg
Midazolam 0.1 mg/kg IV
max 10 mg
7 mg
Midazolam IM
RAMPART weight band
10 mg
Midazolam 0.2 mg/kg IN
max 10 mg
10 mg
Diazepam 0.2 mg/kg IV
max 10 mg
10 mg
Diazepam 0.5 mg/kg PR
max 20 mg
20 mg
Second-line load
Levetiracetam 60 mg/kg IV / 10 min
max 4500 mg
4,200 mg
Fosphenytoin 20 mg PE/kg IV
max 1500 mg PE · ≤150 mg PE/min
1,400 mg PE
Valproate 40 mg/kg IV / 10 min
max 3000 mg
2,800 mg
Phenobarbital 18 mg/kg IV
≤50 mg/min
1,260 mg
RSI (if refractory)
Ketamine 1.5 mg/kg IV
105 mg
Rocuronium 1.2 mg/kg IV
84 mg
Continuous infusion loads
Midazolam load 0.2 mg/kg
then 0.05–2 mg/kg/hr
14 mg
Propofol load 1.5 mg/kg
then 30–200 mcg/kg/min
105 mg
Ketamine load 1.5 mg/kg
then 1–10 mg/kg/hr
105 mg
0–5 min · initial assessment
  • ABCs · jaw thrust / NPA · O₂ NRB · suction · IV ×2 · monitor · capnography
  • Fingerstick glucose — give D50 25 g IV (peds D10 5 mL/kg) if < 60
  • Thiamine 100 mg IV before/with dextrose if EtOH/malnourished
  • Pregnancy test, temp, focused neuro/trauma exam, expose for rash/needles
  • Labs: CBC, BMP, Mg, Ca, LFTs, tox, AED levels, lactate, VBG, β-hCG
  • CT head ASAP after stabilization; LP if febrile or AMS without cause
  • Consider eclampsia → Mag sulfate 4–6 g IV over 20 min
  • Consider INH overdose → 5 g IV (or g-for-g)
5–20 min · first-line benzodiazepines (give full dose, repeat ×1)
  • IV access
    0.1 mg/kg IV (max 4 mg/dose), repeat in 5 min if seizing
  • No IV — IM
    10 mg IM (≥ 40 kg) or 5 mg IM (13–40 kg); peds 0.2 mg/kg IM — RAMPART trial: IM mid ≥ IV loraz
  • No IV — buccal / intranasal / rectal
    0.2 mg/kg IN (max 10 mg) · 0.5 mg/kg PR
  • Backup IV
    0.15–0.2 mg/kg IV (max 10 mg/dose), repeat ×1

Under-dosing benzos is the most common ED error — give the full mg/kg, then move on.

20–40 min · second-line load (any one — equipoise per ESETT)
  • Levetiracetam (Keppra)
    60 mg/kg IV over 10 min (max 4500 mg) — preferred: no BP/QT effect, no interactions
  • Fosphenytoin
    20 mg PE/kg IV at ≤ 150 mg PE/min (max 1500 mg PE) — telemetry; hypotension, bradycardia
  • Valproate
    40 mg/kg IV over 10 min (max 3000 mg) — avoid pregnancy, hepatic disease, mitochondrial dz
  • Phenobarbital (alternative)
    15–20 mg/kg IV at ≤ 50 mg/min — sedation/respiratory depression, often needs intubation
40+ min · refractory → intubate + continuous infusion
  • RSI
    1–2 mg/kg IV (anti-seizure) + 1.2 mg/kg IV. Avoid long-acting paralytics that mask seizing.
  • Midazolam drip
    Load 0.2 mg/kg IV → 0.05–2 mg/kg/hr
  • Propofol drip
    Load 1–2 mg/kg IV → 30–200 mcg/kg/min — watch PRIS, hypotension
  • Ketamine drip
    Load 1–2 mg/kg → 1–10 mg/kg/hr — preserves BP
  • Phenobarbital / pentobarbital coma
    Last resort; cEEG burst-suppression; ICU only.

Get cEEG ASAP — non-convulsive status persists in ~ 20% after motor activity stops.

Disposition & consults
  • Neurology consult; admit ICU if intubated, refractory, or needs cEEG
  • Single first seizure, fully recovered, normal workup → may discharge with neuro f/u
  • Identify trigger: missed AED, EtOH withdrawal, infection, ICH/SAH/stroke, tox, hypoNa, hypoglycemia, eclampsia
  • Counsel on driving restriction per state law; medication adherence

Educational aid only — verify against local protocol & current NCS / AES guidelines.