Status Epilepticus (Epilepsy/Seizure) ✅

⏱️ 0–5 minutes: Immediate safety + ABC

• Call for help early: crash team, resus team, ICU outreach, anaesthetics or senior medical help depending on setting.
• Check for an individualised epilepsy emergency management plan if immediately available, and follow it while continuing ABC resuscitation.
• Protect from injury; do not restrain; remove hazards; loosen tight clothing around the neck; place in the recovery position when feasible.
• Airway: suction, jaw thrust, consider airway adjuncts if tolerated, and prepare for bag-mask ventilation.
• Breathing: monitor SpO₂, support ventilation if needed, and give high-flow oxygen if hypoxaemic, cyanosed, peri-arrest, or if saturations cannot be reliably measured during ongoing convulsions. Once stable, titrate oxygen to 94–98%, or 88–92% if at risk of hypercapnic respiratory failure.
• Circulation: ECG monitoring, blood pressure, pulse, IV access x2 if possible.
• Glucose: check capillary glucose immediately. If low, treat without delay.
• Hypoglycaemia treatment - typical adult:
  • Give IV glucose 10%, for example 100–200 mL, and recheck glucose.
  • If no IV access, give IM glucagon 1 mg.
  • Consider IV Pabrinex / thiamine before or alongside glucose if alcohol misuse, malnutrition or Wernicke risk is suspected, according to local protocol.
• Bloods, but do not delay treatment: FBC, U&E, LFT, calcium, magnesium, glucose, CRP, CK, VBG/ABG ± lactate, toxicology/ethanol if indicated, pregnancy test where relevant, and antiseizure medication levels if applicable.
• Check temperature; start cooling measures if hyperthermic.
• Treat obvious triggers early, such as sepsis, electrolyte disturbance, drug toxicity, withdrawal, meningitis or encephalitis.

⏱️ 5–10 minutes: First-line benzodiazepine

• Check what has already been given by carers, ambulance staff, care home staff or family. Include pre-hospital buccal midazolam or rectal diazepam in the maximum of 2 benzodiazepine doses.
• Give one benzodiazepine dose promptly via the fastest appropriate route.
• Community or no IV access: give buccal midazolam, or rectal diazepam if midazolam is unavailable or unsuitable.
• Hospital with IV access and resuscitation facilities: give lorazepam 4 mg IV slowly. Monitor respiration closely.
• If no IV access in hospital: use buccal, intramuscular or intranasal midazolam according to local protocol.
• Airway warning: benzodiazepines can cause hypoventilation, especially after repeated doses. Be ready to use airway manoeuvres and bag-mask ventilation.
• Pregnancy with suspected eclampsia: give magnesium sulfate 4 g IV loading dose, then infusion according to obstetric protocol, and call obstetrics, anaesthetics and senior help urgently.

⏱️ 10–20 minutes: If ongoing, repeat benzodiazepine once

• If convulsions persist after the initial dose, repeat one further benzodiazepine dose after approximately 5–10 minutes.
• Do not exceed 2 benzodiazepine doses unless under senior specialist direction, because seizure-control benefit falls while respiratory depression risk rises.
• Continue continuous monitoring and prepare second-line IV antiseizure loading treatment.
• Escalate early to anaesthetics/ICU if seizures continue, airway risk is rising, or second-line treatment is being prepared.

⏱️ 20–30 minutes: Second-line IV antiseizure loading - choose one

• Start a loading dose promptly if seizures continue after two benzodiazepine doses. Choice depends on comorbidity, pregnancy potential, interactions, liver disease, cardiac disease and local availability.
• Levetiracetam: 60 mg/kg IV, maximum 4.5 g, over 10–15 minutes.
  • Often practical because it has fewer drug interactions and is relatively easy to administer.
  • It may still be used in people already prescribed levetiracetam, but check local or specialist advice.
• Phenytoin: 20 mg/kg IV, maximum 2 g, at no more than 50 mg/min.
  • Use ECG and blood pressure monitoring.
  • Avoid or use extreme caution in severe conduction disease, bradyarrhythmia or significant cardiac disease.
  • Watch for extravasation injury and drug interactions.
• Sodium valproate: 40 mg/kg IV, maximum 3 g, over about 10 minutes.
  • Avoid in pregnancy.
  • Generally avoid in women and girls of childbearing potential unless specialist advice confirms that no suitable alternative is appropriate.
  • Follow MHRA valproate safety measures.
  • Avoid in significant liver disease and suspected mitochondrial disorders.
• Escalate early: alert ICU/HDU, anaesthetics and neurology when giving second-line therapy.

⏱️ ≥30 minutes: Refractory status epilepticus - expert guidance, phenobarbital and/or ICU anaesthesia

• If seizures persist after second-line treatment, seek urgent neurology, ICU and anaesthetic guidance.
• Consider phenobarbital or general anaesthesia under expert guidance.
• If general anaesthesia is used: secure airway, intubate, ventilate and start an anaesthetic infusion according to ICU protocol.
• Common ICU infusions include propofol or midazolam; monitor for hypotension and complications. Prolonged high-dose propofol carries risk of propofol infusion syndrome.
• Use continuous EEG if available, because convulsive status can evolve into non-convulsive status epilepticus after motor activity stops.
• Actively correct physiology: oxygenation, ventilation, temperature, glucose, sodium, calcium, magnesium, acidosis and renal function.

Beyond refractory status: Specialist strategies

• Ketamine may be considered in specialist settings, particularly later when NMDA-mediated excitation is more important.
• Barbiturate anaesthesia, for example thiopental or pentobarbital, may be used in specialist ICUs.
• Consider immune, infective and structural causes early, including autoimmune encephalitis, HSV encephalitis, meningitis, stroke, haemorrhage and tumour.
• Start empirical antimicrobial or antiviral treatment promptly if infection or encephalitis is suspected; do not wait for LP if this would cause delay.

🧠 Post-stabilisation - once safe

• Confirm seizure termination clinically and with EEG if there is any doubt. Persistent coma, fluctuating awareness or subtle twitching may indicate non-convulsive status epilepticus.
• Neuroimaging: CT head urgently if first seizure, focal neurological deficit, immunosuppression, head injury, anticoagulation, persistent reduced GCS, or suspicion of haemorrhage, stroke, tumour or raised intracranial pressure.
• Lumbar puncture: perform if meningitis or encephalitis is suspected, after imaging if raised intracranial pressure risk is present.
• Empirical therapy: if HSV encephalitis is suspected, start IV aciclovir immediately; do not wait for LP if delayed.
• Antiseizure medication plan: optimise long-term treatment, check adherence, interactions and levels where relevant, and involve neurology or the epilepsy team.
• Emergency plan: after recovery, agree or update an individualised emergency management plan if prolonged seizures or status epilepticus may recur.
• Driving and safety: give appropriate advice about driving restrictions, bathing, swimming, heights, machinery and occupational risks.

⚠️ Common causes and triggers

• Known epilepsy: missed antiseizure medication, sleep deprivation, alcohol use or withdrawal, infection, interacting drugs, vomiting, malabsorption or recent medication changes.
• New-onset seizures: stroke, intracranial haemorrhage, tumour, meningitis, encephalitis, head injury, hyponatraemia, hypocalcaemia, hypoglycaemia, toxins, drugs or alcohol withdrawal.
• Mimics: psychogenic non-epileptic seizures, syncope, hypoglycaemia, dystonia, rigors and drug reactions.

🚨 Complications to anticipate

• Airway and respiratory: aspiration, hypoventilation after benzodiazepines, airway obstruction, hypoxia and respiratory failure.
• Systemic: hyperthermia, lactic acidosis, rhabdomyolysis, acute kidney injury, electrolyte disturbance and arrhythmias.
• Neurological: hypoxic brain injury, cerebral oedema and non-convulsive status epilepticus.
• Inpatient risks: pressure injury, aspiration pneumonia and VTE from immobility. Start VTE prophylaxis when safe.