← Guidelines

Status epilepticus

Neurocritical Care Society guidance. The dominant failure mode in practice is under-dosing the first-line drug and then moving on too slowly.

1. Emergent (0–5 min): a benzodiazepine at an adequate dose — intravenous lorazepam, or intramuscular midazolam where access is not established.
2. Urgent control (5–20 min): an intravenous antiseizure medication. The ESETT trial found levetiracetam, fosphenytoin and valproate roughly equivalent, so the choice can rest on contraindications and availability.
3. Refractory (20–40 min): anaesthetic infusion — midazolam, propofol or thiopentone — with continuous EEG monitoring.
4. Throughout: treat the cause. Check glucose, sodium, calcium and toxicology, and image the brain.

Non-convulsive status is a real risk in any patient who does not wake as expected after convulsions stop. Motor activity ceasing is not the same as seizures ceasing — that distinction needs EEG.