Status Epilepticus (Epilepsy/Seizure)

⏱️0–5 minutes: Immediate safety + ABC

• Call for help early (crash team / resus / ICU outreach depending on setting).
• Protect from injury; do not restrain; remove hazards; recovery position when feasible.
• Airway: suction, jaw thrust; consider OPA/NPA if tolerated; prepare bag-mask ventilation.
• Breathing: monitor SpO₂ (± ETCO₂ if available). Give oxygen only if hypoxaemic (target 94–98%; 88–92% if at risk of hypercapnic RF).
• Circulation: ECG, BP; establish IV access (x2 if possible).
• Glucose immediately (capillary): if low, treat without delay.
• Hypoglycaemia treatment (typical adult):
  • IV glucose 10% (e.g. 100–200 mL) and recheck; or IM glucagon 1 mg if no IV access.
  • Consider IV Pabrinex / thiamine if alcohol misuse/malnutrition (local protocol).
• Bloods (do not delay treatment): FBC, U&E, LFT, Ca²⁺, Mg²⁺, glucose, CRP, CK, VBG/ABG ± lactate; toxicology/ethanol if indicated; pregnancy test where relevant; antiseizure drug levels if applicable.
• Check temperature; start cooling measures if hyperthermic.
• Treat obvious triggers early (e.g. sepsis bundle; consider meningitis/encephalitis where indicated).

⏱️5–10 minutes: First-line benzodiazepine (give ONE dose promptly)

• Give one benzodiazepine dose promptly via the fastest available route.
• If IV access available: Lorazepam 4 mg IV slow (≈0.1 mg/kg, max 4 mg); monitor respiration.
• If no IV access / community:
  • Midazolam 10 mg buccal (or IM/IN per local protocol).
  • Alternative: Diazepam 10 mg PR if midazolam unavailable.
• Airway warning: benzodiazepines can precipitate hypoventilation — be ready to bag-mask ventilate.
• Pregnancy (suspected eclampsia): magnesium sulfate 4 g IV bolus then infusion per obstetric protocol + urgent obstetrics/anaesthetics.

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

• If convulsions persist after initial dose, repeat one further benzodiazepine dose after ~5–10 minutes.
• Do not exceed 2 benzodiazepine doses — diminishing seizure-control benefit + rising respiratory risk.
• Continue continuous monitoring; prepare second-line drug + airway plan.

⏱️20–30 minutes: Second-line IV antiseizure loading (choose ONE)

• Start a loading dose promptly; choice depends on comorbidity, pregnancy, interactions, and local availability.
• Levetiracetam 60 mg/kg IV (max 4.5 g) over 10–15 minutes — minimal interactions, practical in uncertain aetiology.
• Phenytoin 20 mg/kg IV (max 2 g) at ≤50 mg/min with ECG/BP monitoring; avoid in severe conduction disease; extravasation risk.
• Sodium valproate 40 mg/kg IV (max 3 g) over ~10 minutes — avoid in pregnancy, significant liver disease, and suspected mitochondrial disorders.
• Escalate early: alert ICU/HDU + anaesthetics when giving second-line therapy.

⏱️≥30 minutes: Refractory status → ICU, intubate + anaesthetic infusion

• ICU escalation: secure airway, intubation and ventilation.
• Continuous infusion per ICU protocol (examples): propofol or midazolam infusion (monitor hypotension; prolonged high-dose propofol risks).
• Continuous EEG if available (convulsions can convert into non-convulsive status).
• Actively treat physiology: oxygenation/ventilation, temperature control, glucose, electrolytes.

Beyond (super-refractory): Specialist strategies

• Ketamine (NMDA antagonism may be more useful later).
• Barbiturate anaesthesia (e.g. thiopental/pentobarbital) in specialist ICUs.
• Consider immune/infective causes early (autoimmune encephalitis, HSV, meningitis) and treat empirically when indicated.

🧠 Post-stabilisation (once safe)

• Confirm termination clinically and with EEG if doubt — non-convulsive status is common post-convulsion.
• Neuroimaging: CT head urgently if first seizure, focal deficit, immunosuppression, head injury, anticoagulation, persistent reduced GCS, suspicion of haemorrhage/stroke/tumour.
• LP if infection/encephalitis suspected (after imaging if raised ICP risk).
• Empiric therapy: if HSV encephalitis suspected, start IV aciclovir immediately (do not wait for LP if delayed).
• AED plan: optimise long-term regimen, check adherence/levels where relevant; refer to neurology/epilepsy team.

⚠️ Common causes / triggers

• Known epilepsy: missed doses, sleep deprivation, alcohol/withdrawal, infection, interacting drugs.
• New-onset: stroke/ICH, tumour, meningitis/encephalitis, head injury, metabolic (Na⁺, Ca²⁺, glucose), toxins/drugs.
• Mimics: PNES, syncope, hypoglycaemia, dystonia/drug reactions.

🚨 Complications to anticipate

• Airway/respiratory: aspiration, hypoventilation (esp. after benzodiazepines), respiratory failure.
• Systemic: hyperthermia, lactic acidosis, rhabdomyolysis (check CK), AKI, arrhythmias.
• Neurological: hypoxic brain injury, cerebral oedema, non-convulsive status (needs EEG).
• Inpatient risks: VTE from immobility — prophylaxis when safe.