Recommendations
Urgent
Convulsive status epilepticus is a medical emergency that needs immediate treatment with anticonvulsant therapy.[1] Aim for prompt evaluation and rapid management to prevent neurological damage and death. Manage and investigate concurrently.[16]
Suspect convulsive status epilepticus in a patient with seizures that continue for longer than 5 minutes.[1][17]
Characteristic findings include:[17]
Intermittent or continuous tonic-clonic seizures involving stiffening of the whole body (tonic phase) followed by vigorous shaking (clonic phase).[17]
Mental status impairment (coma, lethargy, confusion).[17]
The patient will typically have their eyes open and be unresponsive to commands or sensory stimuli.[18]
Consider the possibility of non-epileptic seizures (dissociative seizures).[16]
Take a focused collateral history from family, carers, and/or witnesses.
Attempt intravenous access in a large vein and take emergency bloods for:[16]
Glucose[19]
Arterial blood gas[16]
Urea[19]
Creatinine[16]
Liver function tests[16]
Clotting screen[1]
Anticonvulsant drug levels (irrespective of a known history of epilepsy).[16]
Consider a toxicology screen (blood and urine samples) if you suspect substance misuse/overdose.[19]
Provide resuscitation.[1] Once you have excluded non-epileptic seizures, do not delay emergency treatment by waiting for test results. See Management.
Key Recommendations
[Figure caption and citation for the preceding image starts]: Convulsive status epilepticus: key diagnostic and management recommendations flowchart. BP, blood pressure; Ca, calcium; CRP, C-reactive protein; ECG, electrocardiogram; EEG, electroencephalogram; FBC, full blood count; GCS, Glasgow Coma Scale; ICU, intensive care unit; Mg, magnesium; Na, sodiumCreated by the BMJ Knowledge Centre based on key references (see references page) [Citation ends].
Suspect non-convulsive status epilepticus (NCSE) in:[20]
A patient with a previous diagnosis of epilepsy: if there is any prolonged change in personality, prolonged post-ictal confusion (greater than 20 minutes), or recent-onset psychosis
A non-comatose patient with no history of epilepsy: if there is confusion or change in personality (typically seen in the setting of a metabolic derangement, encephalitis, or other acute precipitant).
If you suspect NCSE, refer the patient to the neurology team for specialist clinical assessment. Be aware that NCSE can follow convulsive status epilepticus.
Convulsive status epilepticus
Suspect convulsive status epilepticus in a patient with seizures that continue for longer than 5 minutes.[1][17]
The seizures will be intermittent or continuous tonic-clonic seizures involving stiffening of the whole body (tonic phase) followed by vigorous shaking (clonic phase).[17]
Mental status impairment (coma, lethargy, confusion) is a characteristic finding.[17]
The patient will typically have their eyes open and be unresponsive to commands or sensory stimuli.[18][21]
Manage and investigate the patient concurrently.[16] Aim for prompt evaluation and rapid management to prevent immediate complications (e.g., neurological deficits, cognitive dysfunction) and long-term sequelae.[16] Specifically, seek to achieve seizure control within the first 1 to 2 hours after onset of symptoms as this will significantly affect the prognosis.[22] Convulsive status epilepticus is:
A medical emergency[1]
The most common presentation of status epilepticus. It is associated with significant morbidity and a mortality of 16% to 39%.[23][24][25][26][27]
Non-convulsive status epilepticus
Suspect non-convulsive status epilepticus:[20]
In a patient with a previous diagnosis of epilepsy: if there is any prolonged change in personality, prolonged post-ictal confusion (greater than 20 minutes), or recent-onset psychosis
In a non-comatose patient with no history of epilepsy: if there is confusion or personality change (typically seen in the setting of a metabolic derangement, encephalitis, or other acute precipitant).
If you suspect non-convulsive status epilepticus, refer the patient to the neurology team (recommendation based on clinical experience).
Non-convulsive status epilepticus can follow convulsive status epilepticus.
Practical tip
Be aware that non-convulsive status epilepticus is much less common than convulsive status epilepticus and can be easily missed because motor findings are limited or absent.
Consider the possibility of non-epileptic (dissociative) seizures (previously termed psychogenic non-epileptic seizures).[1]
Non-epileptic seizures are a common cause of prolonged convulsions and can be confused with status epilepticus, given the two present in a similar manner.[1][21] Key features of non-epileptic seizures include:[16]
Long (>5 minutes) duration of individual seizures
Fluctuating course (waxing and waning)
Asynchronous rhythmic movements
Pelvic thrusting
Side-to-side head/body movements during a convulsion
Closed eyes
Ictal crying
Later recall of items during the seizure.
Practical tip
Non-epileptic seizures are the most important differential in the emergency setting. Emergency anticonvulsant drug therapy is not only ineffective but also potentially dangerous, putting patients at risk of respiratory depression, aspiration, and death.[21] Seek specialist advice if you suspect non-epileptic seizures.
See Differentials for other mimics.
Take a focused collateral history from family, carers, and/or witnesses. Concurrently manage the patient.[16]
Establish:
Approximate duration of the convulsion. Time a seizure from its onset if possible[28]
Whether the patient already has a diagnosis of epilepsy
Whether any medication has already been given to terminate the seizure[21]
Any symptoms preceding the seizure that may suggest its cause (e.g., hypoglycaemia, thiamine deficiency, meningitis)[1][21]
Whether the patient is pregnant. If the gestational age is ≥20 weeks, consider eclampsia.[1][21] See Pre-eclampsia.
Relevant past medical history, including:[21]
Diabetes
Hypertension
Heart disease
Medication use[21]
Alcohol-use disorder[14]
Any other potential provoking factors, including recent recreational drug use (e.g., cocaine, amphetamines).[21]
Practical tip
Status epilepticus usually resolves after restarting anticonvulsant medication in patients with epilepsy. However, bear in mind that people with epilepsy may have an acute cause for their status epilepticus.[11]
Convulsive status epilepticus
Assess the patient’s respiratory and cardiac function.[27] In particular, check:
Colour for cyanosis, pallor
Airway for signs of obstruction
Breathing rate and quality
Pulse rate and volume
Blood pressure
Chest (auscultate).
Assess the patient’s level of consciousness. Check pupils for size and reactivity.
Use the Glasgow Coma Scale (GCS). [ Glasgow Coma Scale Opens in new window ]
Status epilepticus is associated with an altered/reduced level of consciousness.
Mydriasis is a common finding in epileptic seizures.
Examine the patient’s abdomen.
If there is a palpable uterus, the patient may have eclampsia.[21] See Pre-eclampsia.
Non-convulsive status epilepticus
Refer the patient to the neurology team for specialist clinical assessment (recommendation based on clinical experience).
Laboratory tests
Once you have excluded non-epileptic seizures (dissociative seizures), do not delay emergency treatment by waiting to take samples or receive results (this recommendation is based on clinical experience).
Take emergency bloods in all patients for:
Glucose[19]
Hypoglycaemia and hyperglycaemia are treatable and reversible causes of seizures and status epilepticus
Arterial blood gases[16]
May show abnormal values in the presence of acidosis or alkalosis
Significant metabolic abnormalities are common following prolonged seizures. These usually normalise following seizure termination
Urea[19]
Elevation may provoke acute symptomatic seizures[19]
Creatinine[19]
Take as a baseline measure, to investigate the cause of seizures, and to identify those who might be at particularly high risk of complications such as acute kidney injury (from rhabdomyolysis).[19] See Acute kidney injury
Elevated creatinine may provoke acute symptomatic seizures[19]
May indicate systemic disease or alcohol-use disorder[19]
Sodium calcium, and magnesium[16][19]
Electrolytes abnormalities such as hyponatraemia, hypocalcaemia, and hypomagnesaemia can cause seizures
High levels may indicate infection or systemic inflammation
Clotting screen[19]
Take as a baseline measure and to identify patients with coagulopathy[19]
Anticonvulsant drug levels (irrespective of a known history of epilepsy)[16]
A sub-therapeutic anticonvulsant level is a common cause of status epilepticus in people with epilepsy. This is usually due to poor adherence to treatment.[9]
Consider a toxicology screen (blood and urine samples) if you suspect substance misuse/overdose.[19]
Practical tip
Save 5 mL of serum and 50 mL urine for future analysis, e.g., toxicology.
Chest x-ray
Arrange an emergency chest x-ray to evaluate the possibility of aspiration. See Aspiration pneumonia.
ECG
Consider ECG to evaluate the possibility of arrhythmias or cardiac ischaemia which may be the result of prolonged status epilepticus (and, in rare cases, its cause).
CT-head
Consider an urgent computed tomography (CT)-head in a patient with no previous history of epilepsy or with new focal neurology, head injury, or for any patient with refractory status epilepticus.[16]
Other investigations
If a clear precipitant has not been identified, consider other emergency investigations based on individual clinical circumstances. For example, consider a lumbar puncture for cerebrospinal fluid evaluation if you suspect central nervous system infection or inflammation.[30]
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