Seizure 00:00

Status Epilepticus Management Protocol

Evidence-based clinical decision support — Updated 2025

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Patient Information

Relevant Medical History

Treatment Algorithm

CRITICAL: Status epilepticus is defined as ≥5 minutes of continuous seizure activity. Immediate treatment is essential — efficacy decreases rapidly with time.
Phase 1

Immediate Stabilization

0–5 min
ABCs first: Airway, Breathing, Circulation. Position patient, suction if needed, O₂, IV access, monitor vitals.
First-line: Benzodiazepines
Choose ONE of the following
Lorazepam (preferred if IV access available)
Weight kg
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Dose: 0.1 mg/kg IV (typical adult dose: 4–8 mg). Max rate: 2 mg/min. May repeat once after 5 minutes if seizures continue.
Midazolam (if NO IV access)
10 mg IM (or 0.2 mg/kg, max 10 mg)
Faster than getting IV access. Onset 5–10 minutes. May repeat once.
Diazepam (alternative)
Weight kg
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Dose: 0.15 mg/kg IV (typical: 5–10 mg). Shorter duration of action than lorazepam.
Phase 2

Second-Line Therapy

5–20 min
If seizures continue after adequate benzodiazepine dose, proceed immediately to second-line agent. Don't wait.
Levetiracetam
Weight kg
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Dose: 60 mg/kg IV (max 4500 mg). Infuse over 5–10 minutes. Excellent safety profile, minimal drug interactions.
Fosphenytoin
Weight kg
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Dose: 20 mg PE/kg IV (max 1500 mg PE). Max rate: 150 mg PE/min. Requires close monitoring of BP/HR/O₂ as it can cause hypotension. Hypotension is not a contraindication as long as IV access and pressors are available. Use recommended infusion rates.
Valproate
Weight kg
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Dose: 40 mg/kg IV (max 3000 mg). Infuse over 10 minutes. Avoid in pregnancy or known significant liver/mitochondrial disease. Maintenance dose may need adjustment later for hepatic insufficiency.
Lacosamide
Weight kg
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Dose: 6–8 mg/kg IV (typical: 200–400 mg). Infuse over 15–30 minutes. Check baseline ECG for PR interval; use with caution if prolonged.

Intubation Criteria

Consider intubation if ANY of the following:
  • Refractory status epilepticus (failed 2 appropriate medications)
  • Respiratory depression or failure (RR <10, SpO₂ <90%)
  • Airway compromise or inability to protect airway
  • Hemodynamic instability
  • Concern for elevated intracranial pressure
  • Need for continuous anesthetic infusions
RSI Considerations: Use propofol (anti-seizure properties) or ketamine (1 mg/kg). Avoid succinylcholine if SE >30 minutes (hyperkalemia risk). Consider rocuronium with sugammadex reversal for neuro exam.
Phase 3

Refractory SE

20+ min
REFRACTORY STATUS EPILEPTICUS — Seizures persisting despite adequate doses of benzodiazepine + second-line ASM. Consider intubation and anesthetic agents. Continuous EEG (cEEG) is required to guide therapy.
Ketamine (emerging first choice)
Weight kg
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Dose: 1–2 mg/kg IV bolus, then 1–5 mg/kg/hr infusion. May avoid intubation. Hemodynamically stable. Often given concurrently with a midazolam infusion.
Propofol
1–2 mg/kg IV bolus, then 2–10 mg/kg/hr infusion
Requires intubation. Risk of propofol infusion syndrome with high doses. Monitor lactate, lipids. Consider triglyceride monitoring.
Midazolam infusion
0.2 mg/kg IV bolus, then 0.05–2 mg/kg/hr infusion
Less hypotension than propofol. Good option for hemodynamically unstable patients.
Pentobarbital
Load: 5–15 mg/kg IV, then infusion: 0.5–5 mg/kg/hr
Induces therapeutic coma. Long half-life. High risk of respiratory depression and hypotension; requires intubation and pressor support. Titrate to burst-suppression on cEEG.
Phase 4

Super-Refractory SE

24+ hr
SUPER-REFRACTORY SE — Persisting despite 24+ hours of anesthesia or recurring during anesthetic wean. Requires specialist neurology consultation.
Consider Additional Therapies
  • Therapeutic hypothermia (experimental)
  • High-dose barbiturate coma
  • Inhaled anesthetics
  • Immunotherapy if autoimmune suspected
  • Surgical evaluation for focal lesions
  • Continuous EEG monitoring essential

Key Principles

  • Early treatment is crucial — don't delay
  • Use adequate doses — underdosing is common and harmful
  • Always load maintenance ASM even if benzodiazepines work
  • Consider reversible causes: glucose, thiamine, infection, medication compliance
  • Continuous EEG monitoring for intubated patients
  • Avoid paralysis without EEG monitoring

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