Status epilepticus

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

convulsive status epilepticus: in hospital

1st line – assess and treat using ABC principles

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1st line –

assess and treat using ABC principles

Provide resuscitation and immediate emergency treatment to prevent neurological damage and death.[1] Once you have excluded non-epileptic seizures (i.e., dissociative seizures), do not delay treatment by waiting to take samples or receive results. The longer the duration of convulsive status epilepticus, the worse the prognosis.[16]

Aim to achieve seizure control within the first 1 to 2 hours after onset of seizures.[22]

Note the time. Call for help.

Seek help early to carry out these steps in parallel with other members of the multidisciplinary team.[16]

Take an Airway, Breathing, Circulation (ABC) approach.[16] In particular:

Secure the airway (place the patient in semi-prone position to avoid aspiration); use a nasopharyngeal airway.[16]

Plus – supportive care and monitoring

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Plus –

supportive care and monitoring

Treatment recommended for ALL patients in selected patient group

Give high-concentration oxygen.[21]

Give thiamine (vitamin B1) before or at the same time as glucose if there is any suggestion of alcohol abuse or impaired nutrition.[27] This is usually administered as a high-potency vitamin B preparation (e.g., Pabrinex® in the UK).

Give glucose if the patient is hypoglycaemic.[16]

Treat severe acidosis if present.

Correct electrolyte abnormalities if present.

Start regular monitoring, which may include:

Neurological observations. Use the Glasgow Coma Scale (GCS) [ Glasgow Coma Scale Opens in new window ]
- If GCS score ≤8 (i.e., patient not obeying commands, not speaking, not eye opening) request an urgent intensive care unit review for appropriate airway management[32]
Pulse, blood pressure, temperature[16]
ECG[27]
Biochemistry, blood gases, clotting, blood count[16]
Anticonvulsant levels. Seek advice from the neurology team to guide decisions on which anticonvulsant levels you need to monitor regularly.

Primary options

thiamine: consult local protocol for dose guidelines

Plus – benzodiazepine

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Plus –

benzodiazepine

Treatment recommended for ALL patients in selected patient group

If the patient has an individualised emergency management plan that is immediately available, administer medication as detailed in the plan.[1]

If no emergency management plan is immediately available:[1]

If two adequate doses of any benzodiazepine (e.g., lorazepam, diazepam, midazolam) have been given and seizures have not stopped, progress to second-line anticonvulsant options. See levetiracetam or valproate or phenytoin/fosphenytoin (established status epilepticus) below.[1]
If benzodiazepines have not already been administered in the community, give intravenous lorazepam as first-line treatment if intravenous access and resuscitation facilities are immediately available; maximum of two doses (including pre-hospital).[1]

If convulsive status epilepticus does not respond to the first dose of benzodiazepine:[1]

Seek expert guidance
Continue to follow the patient's individualised emergency management plan, if this is immediately available, or give a second dose of benzodiazepine if the seizure does not stop within 5 to 10 minutes of the first dose.

Give the patient’s usual anticonvulsant therapy (if they are already taking this for known epilepsy) in parallel with emergency treatment.[33]

Practical tip

Follow your local protocol regarding doses and frequency of benzodiazepine therapy. High doses (above those recommended in protocols) can cause reduced consciousness and respiratory depression. However, be aware that the biggest risk to respiratory function in status epilepticus is ongoing seizures, as opposed to respiratory depression from benzodiazepines.[16]

Primary options

lorazepam: 4 mg intravenously as a single dose initially, repeat dose after 5-10 minutes if required

Consider – levetiracetam or valproate or phenytoin/fosphenytoin (established status epilepticus)

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Consider –

levetiracetam or valproate or phenytoin/fosphenytoin (established status epilepticus)

Additional treatment recommended for SOME patients in selected patient group

If seizures continue despite two doses of a benzodiazepine (including pre-hospital), the UK National Institute for Health and Care Excellence (NICE) recommends to give one of the following second-line intravenous anticonvulsants:[1]

Levetiracetam[16][30]
- Levetiracetam may be quicker to administer and have fewer adverse effects than the alternative options recommended by NICE[1]
- Use of levetiracetam is off-label for this indication in the UK
Phenytoin[30]
Sodium valproate.[16][30]

Although not universally available, fosphenytoin is also an option for convulsive status epilepticus that is refractory to benzodiazepines and is typically preferred by experts in practice. Fosphenytoin, a water soluble prodrug of phenytoin, has a number of comparative advantages including fewer infusion site reactions, and availability of an intramuscular formulation allowing for potentially quicker and easier administration.[6][16]

The choice of second-line anticonvulsant depends on:[16][23]

Availability and your local protocols
The type of epilepsy the patient has and their prescribed medication (where applicable and known)
- Poor adherence is a common cause of status epilepticus in people with epilepsy; reloading with the same anticonvulsant may be preferable[9]
Contraindications (e.g., valproate is contraindicated in most women of childbearing age)
Previously ineffective alternatives.

If convulsive status epilepticus does not respond to a second-line treatment, consider trying an alternative second-line treatment option under expert guidance.[1]

Consider vasopressor therapy if needed.[17]

In the context of maintenance treatment of epilepsy, both in Europe and the US, valproate and its analogues are contraindicated during pregnancy because of the risk of congenital malformations and developmental problems in the child. In people with status epilepticus, this is a relative contraindication. Evidence supports a rate of congenital malformations of 10% in infants whose mothers took valproate during pregnancy and neurodevelopmental disorders in approximately 30% to 40% of children.[38] If it is not possible to stop valproate, treatment may be continued with appropriate specialist care. Valproate and its analogues must not be used in female patients of childbearing potential unless there is a pregnancy prevention programme in place and certain conditions are met.[39] If the patient is taking the drug to prevent major seizures and is planning to become pregnant, the decision of continuing valproate versus changing to an alternative agent should be made on an individual basis.

A review of the safety of anticonvulsants (other than valproate) in pregnancy by the UK Medicines and Healthcare products Regulatory Agency concluded that levetiracetam, at maintenance doses, is not associated with an increased risk of major congenital malformations. Available studies also do not suggest an increased risk of neurodevelopmental disorders or delay associated with in-utero exposure to levetiracetam, but data are more limited.[38]

Data for other drugs show an increased risk of major congenital malformations associated with phenytoin, and possible adverse effects on neurodevelopment of children exposed in utero to phenytoin.[38]

Primary options

levetiracetam: consult specialist for guidance on dose

sodium valproate: consult specialist for guidance on dose

phenytoin: 15-20 mg/kg (maximum 2 g/dose) intravenously as a loading dose initially, followed by 100 mg every 6-8 hours

fosphenytoin: 15-20 mg (PE)/kg intravenously as a loading dose initially, followed by 4-5 mg (PE)/kg/day given in 1-2 divided doses

Consider – admission to ICU (refractory status epilepticus)

convulsive status epilepticus: in the community

1st line – benzodiazepine and supportive care ± transfer to hospital

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1st line –

benzodiazepine and supportive care ± transfer to hospital

Note the time and give first aid to people having a tonic-clonic seizure in the community. In particular:[40]

Protect the patient from injury
Do not restrain the patient or put anything in their mouth
If the seizure stops, check the patient's airway and place them in the recovery position.

If the patient with convulsive status epilepticus has an individualised emergency management plan that is immediately available, administer medication as detailed in the plan.[1]

If an emergency management plan is not immediately available, give buccal midazolam or rectal diazepam immediately as first-line treatment:[1]

The National Institute for Health and Care Excellence (NICE) in the UK recommends buccal midazolam as first choice, with rectal diazepam as an alternative if agreed, based on previous use or if buccal midazolam is unavailable.[41]

If convulsive status epilepticus does not respond to the first dose of benzodiazepine:[1]

Call emergency services
Either continue to follow the patient's emergency management plan (if immediately available) or give a second dose of benzodiazepine if the seizure does not stop within 5 to 10 minutes of the first dose.

Give supportive care as needed, if the facilities are available. In particular:[21]

Secure the airway: consider a nasopharyngeal airway
Give high-concentration oxygen.

Primary options

midazolam: 10 mg buccally as a single dose initially, repeat dose after 5-10 minutes if required

Secondary options

diazepam rectal: 10-20 mg rectally as a single dose initially, repeat dose after 5-10 minutes if required

non-convulsive status epilepticus

1st line – refer to neurology

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Status epilepticus

convulsive status epilepticus: in hospital

assess and treat using ABC principles

supportive care and monitoring

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

benzodiazepine

Practical tip

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

levetiracetam or valproate or phenytoin/fosphenytoin (established status epilepticus)

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

admission to ICU (refractory status epilepticus)

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

convulsive status epilepticus: in the community

benzodiazepine and supportive care ± transfer to hospital

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

non-convulsive status epilepticus

refer to neurology

Status epilepticus

Treatment algorithm

convulsive status epilepticus: in hospital

assess and treat using ABC principles

supportive care and monitoring

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

benzodiazepine

Practical tip

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

levetiracetam or valproate or phenytoin/fosphenytoin (established status epilepticus)

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

admission to ICU (refractory status epilepticus)

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

convulsive status epilepticus: in the community

benzodiazepine and supportive care ± transfer to hospital

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

non-convulsive status epilepticus

refer to neurology