Status Epilepticus

Aka: Status Epilepticus, Seizure Emergency Management

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II. Epidemiology

  1. Prevalence: 152,000 cases per year in United States
  2. Age (Bimodal distribution)
    1. Adults: Highest Incidence after age 60 years
    2. Children: Highest Incidence under age 1 year

III. Definitions

  1. Status Epilepticus Diagnostic criteria (2015)
    1. Single unremitting Seizure lasting >5 minutes OR
    2. Frequent clinical Seizures (>=2) without inter-ictal return to baseline lasting longer than 5 minutes
    3. Trinka (2015) Epilepsia 56(10): 1515-23 [PubMed]
  2. Older classical Status Epilepticus diagnostic criteria (deprecated, do NOT use)
    1. Continuous Seizure activity longer than 30 minutes (Neuronal damage occurs within 30 min) or
    2. Two or more sequential Seizures
      1. No recovery of consciousness between Seizures

IV. Pathophysiology

  1. Excessive excitation (excess Glutamate)
  2. Ineffective inhibition (inadequate GABA)
    1. GABA aminobutyric receptors are also targeted by Benzodiazepines, Propofol
  3. With prolonged Seizures
    1. GABA Receptors (inhibitory) decrease on cell surface (Seizure becomes refractory)
    2. NMDA receptors (excitatory) increase on cell surface

V. Types

  1. Convulsive Status Epilepticus
    1. Rhythmic jerking and generalized tonic clonic activity with Altered Mental Status
  2. NonConvulsive Status Epilepticus
    1. Electrographic (EEG) Seizure activity without clinical Seizure activity
  3. Refractory Status Epilepticus
    1. Persistent clinical or EEG Seizure activity despite 2 antiepileptic agents
    2. Affects 10-40% of children with Status Epilepticus

VI. Causes

  1. See Seizure Causes
  2. Poor Medication Compliance with low anticonvulsant drug levels
  3. Alcohol Withdrawal
  4. Drug Overdose (e.g. INH Overdose)
  5. Toxin Ingestion
  6. Intracranial Infection
    1. Meningitis
    2. Encephalitis
  7. Intracerebral Hemorrhage
  8. Cerebral Neoplasm
  9. Metabolic disorder
    1. Electrolyte disturbance (especially Sodium, Calcium and Phosphorus)
    2. Inborn Errors of Metabolism
    3. Vitamin B6 Deficiency

VII. Signs

  1. See definition above
  2. Witnessed persistent Seizure
  3. Consciousness not regained within 5 minutes of Seizure
  4. Signs may be subtle (e.g. tonic Eye Deviation)

VIII. Labs

  1. Bedside Glucose
  2. Serum Electrolytes (e.g. Basic Metabolic panel with additional labs)
    1. Serum Sodium
    2. Serum Calcium
    3. Serum Phosphorus
    4. Serum Magnesium
    5. Renal Function tests (Serum Creatinine and Blood Urea Nitrogen)
  3. Hepatic panel
  4. Venous Blood Gas
  5. Antiepileptic drug levels
  6. Urine Tox Screen
  7. Complete Blood Count
  8. Pregnancy Test (Eclampsia risk)

IX. Differential Diagnosis

  1. See Altered Level of Consciousness
  2. See causes as above
  3. Rapidly reversible causes (with specific treatments)
    1. Hypoglycemia
    2. Eclampsia
    3. Hyponatremia
    4. Alcohol Withdrawal
    5. Isoniazid Overdose

X. Diagnostics: Indicated for refractory Status Epilepticus

  1. Head CT
  2. Lumbar Puncture
  3. Electroencephalogram (EEG)
    1. Continuous video EEG is preferred
    2. Also consider in persistent encephalopathy or abnormal behaviors (risk of nonconvulsive status)

XI. Management: Initial

  1. See ABC Management
  2. Control airway
    1. Nasal Airway
    2. Consider intubation
  3. Obtain IV Access with Normal Saline to keep open
  4. Administer Supplemental Oxygen
  5. Treat reversible causes (see below)
    1. Includes finger stick Glucose (and administer dextrose if <70 mg/dl)
  6. Monitor Vital Signs closely
    1. Especially Temperature
    2. Telemetry
    3. Electrocardiogram

XII. Management: Rapidly Reversible Causes

  1. DONT Mnemonic (Dextrose, Oxygen, Naloxone, Thiamine)
  2. Treat Hypoglycemia if present (based on bedside Glucose - consider if Glucose <80 mg/dl)
    1. Neonate: 0.5 mg/kg (5 ml/kg) D10W
    2. Child: 0.5 mg/kg (2 ml/kg) D25W
    3. Adult: 50 ml IV of D50W
  3. Consider Thiamine in Alcoholism or nutritional deficiency
    1. Thiamine 100 mg IV or IM or
    2. Thiamine 500 mg IV every 8 hours is used in Wernicke's Encephalopathy
  4. Infants under age 2 years (empiric for Autosomal RecessivePyridoxine dependent Seizures)
    1. Pyridoxine 10-15 mg/kg up to 100 mg IV
  5. Severe Hyponatremia (esp. Serum Sodium <120 mEq/L)
    1. Hypertonic Saline (3%) 2 ml/kg (or 150 ml in an adult) over 10 minutes
      1. Expect a 3 mEq/L rise in Serum Sodium
      2. May repeat up to a total of 5 ml/kg (some references 10 ml/kg) if persistent Status Epilepticus
    2. Consider in infants <3 months mistakenly fed free water
  6. Eclampsia
    1. Magnesium Sulfate load 4 to 6 grams IV over 15-20 minutes, then maintain 2 to 3 g/hour
  7. Hypertensive Encephalopathy (PRES)
    1. Blood Pressure lowering no more than 20% within the first 1 to 2 hours
  8. Alcohol Withdrawal
    1. See Alcohol Withdrawal
    2. Benzodiazepines (preferred in Cirrhosis, polysubstance abuse) OR
    3. Phenobarbital Single Agent Alcohol Withdrawal Protocol
      1. Avoid if Benzodiazepines have already been loaded to abort Seizure (apnea, Hypotension risk)
    4. Other measures
      1. Consider associated Closed Head Injury
      2. Administer Thiamine 100 mg IV
        1. Consider high dose Thiamine 500 mg IV every 8 hours (if encephalopathy)
      3. Consider Pyridoxine (as in Isoniazid Overdose) in longstanding Alcohol Use Disorder
  9. Isoniazid Overdose
    1. Pyridoxine 70 mg/kg (up to 5 g) IV over 3 to 5 minutes
    2. Benzodiazepines
  10. Other serious causes with specific emergent management to consider
    1. Meninigitis or Encephalitis
    2. Intracerebral Hemorrhage

XIII. Management: Protocol

  1. Precautions
    1. Ensure ABC Management and reversible cause management (e.g. Hypoglycemia) as above
    2. Goal of Status Epilepticus management is definitive Seizure control within 20-60 minutes of onset
    3. Seizures are harder to control beyond 20 minutes due to loss of GABA Receptors
    4. Post-ictal period and Somnolence may persist longer than typical 30 minutes following Status Epilepticus
    5. One third of Status Epilepticus cases are refractory to Benzodiazepines
    6. Following Benzodiazepines
      1. No evidence for one antiepileptic over another (Keppra, Phenytoin, Valproic Acid) in adults or children
        1. (2014) Ann Emerg Med 63(4): 437-47 [PubMed]
        2. Kapur (2019) N Engl J Med 381(22):2103-2113 [PubMed]
      2. Second-line agents fail 50% of the time
        1. Kapur (2019) N Engl J Med 381(22): 2103 [PubMed]
        2. Dalziel (2019) Lancet 393(10186):2135-45 [PubMed]
        3. Lyttle (2019) Lancet 393(10186):2125-34 [PubMed]
  2. First: Benzodiazepines (choose one)
    1. Precautions
      1. Do not underdose (give full dose early to have best chance to terminate Seizure)
      2. IV Lorazepam and IV Diazepam have equivalent efficacy in Status Epilepticus
      3. Midazolam IM, intranasal or buccal may be more effective than Diazepam IV or rectal
      4. Benzodiazepine effectiveness decreases (and respiratory depression increases) with each subsequent dose
      5. Neonatal Seizure
        1. Call pharmacy at presentation to have Phenobarbital available in case Benzodiazepines fail
    2. Lorazepam (Ativan)
      1. IV: 0.1 mg/kg IV (<2 mg/minute) up to 4 mg
      2. Rectal: 0.1 mg/kg up to 4 mg
      3. May repeat once in 5-10 minutes
      4. Avoid more than 2 doses in children due to risk of respiratory depression
      5. Phamacokinetics: Onset in 2-3 minutes with duration of action 12-24 hours
      6. Avoid IM Lorazepam (unreliable in Status Epilepticus)
    3. Diazepam (Valium)
      1. Intravenous: 0.1 to 0.3 mg/kg IV up to 8-10 mg/dose maximum
        1. May repeat once in 5 minutes
      2. Rectal: 0.5 mg/kg per Rectum up to maximum of 20 mg
        1. Instill via lubricated Feeding Tube inserted 4-5 cm into the Rectum OR
        2. Via tuberculin syringe (without needle) intra-rectally
        3. Hold buttocks closed after instilling medication
      3. Pharmacokinetics: Onset in 1-3 minutes with duration of action 5-15 minutes
        1. Must be immediately followed with longer acting anticonvulsant (e.g. Fosphenytoin) due to short duration
      4. Efficacy
        1. Diazepam is as effective as Lorazepam in Status Epilepticus
          1. Chamberlain (2014) JAMA 311(16): 1652-60
        2. Diazepam IM dosing is as effective as IV dosing
          1. However, other studies have demonstrated more erratic absorption
          2. Midazolam is preferred IM
          3. Silbergleit (2012) N Engl J Med 366:591-600 [PubMed]
    4. Midazolam (Versed)
      1. Preferred Intramuscular agent (when no IV Access available)
        1. Alternative when longer acting Benzodiazepines not available or without IV Access (e.g. Ambulance)
        2. Midazolam IM, intranasal or buccal may be more effective and more rapid than Diazepam IV or rectal
        3. Lorazepam and Diazepam are preferred if available for other routes
      2. IV: 0.15 mg/kg up to 4 mg (then infused IV at 1 mcg/kg/min and titrated every 5 min as needed) up to 10 mg
      3. IM: 0.2 mg/kg of the IV formulation up to 10 mg
        1. Weight 13-40 kg: 5 mg IM
        2. Weight >40 kg: 10 mg IM
      4. Rectal: 0.25 to 0.5 mg/kg
        1. May be delivered via tuberculin syringe (without needle) intra-rectally
        2. Commercial preparations are available for home use (Diastat AcuDial at $300 for 2 doses, age >2)
      5. Intranasal
        1. Dose: 0.2 to 0.4 mg/kg up to 10 mg of the IV formulation
        2. Typically given via syringe with MADD atomizer attached (roughly $15)
        3. Commercial preparations are available for home use (Nayzilam at $550 for 2 doses, age>12)
      6. Buccal mucosa: 0.5 mg/kg of the IV formulation
  3. Next (if refractory after 5 minutes): Choose one
    1. If Neonatal Seizure skip to Phenobarbital below (due to higher efficacy in this age group)
    2. Not effective in Alcohol Withdrawal (continue with Benzodiazepines)
    3. Pharmacokinetics: Both agents have onset within 10-30 minutes with a duration of action of 12-24 hours
    4. Do not delay starting a second agent if no response to initial Benzodiazepines
    5. Fosphenytoin (Cerebyx)
      1. Dose: 20 mg/kg IV or IM (at 3 mg/kg/min up to 150 mg/min) up to 1500 mg maximum
        1. Deliver slowly over 7 minutes
      2. Preferred over Phenytoin
        1. Fosphenytoin can be infused with dextrose
        2. Fosphenytoin has lower risk of Arrhythmia (due to no Ethylene Glycol in base)
        3. Fosphenytoin may be given IM or delivered a faster IV rate (not tissue toxic)
          1. However onset of activity is similar to that with Phenytoin
          2. Fosphenytoin is converted to active Phenytoin form
    6. Phenytoin (Dilantin) - Fosphenytoin is preferred instead (see above)
      1. Dose: 20 mg/kg IV (at 1 mg/kg/min up to 50 mg/min) up to to 1500 mg maximum
        1. Deliver very slowly over 20 minutes
      2. May repeat once with Phenytoin 5-10 mg/kg IV
      3. Maintenance with Phenytoin 50 mg/min
    7. Levetiracetam (Keppra)
      1. Dosing recommended in Status Epilepticus is higher
        1. Dose: 60 mg/kg IV (up to 4500 mg/dose) for single dose
      2. Typical dosing
        1. Load: 20-30 mg/kg IV at 5 mg/kg/min (may give additional second 20 mg/kg IV dose)
        2. Maximum: 3000 mg (or 80 mg/kg/day)
      3. IV formulation is not FDA approved in children
      4. Keppra is as effective as Phenytoin as second-line after initial Benzodiazepine dosing in children and adults
        1. Noureen (2019) J Clin Neuro 15(4): 468-72 [PubMed]
    8. Valproic Acid (Depakote)
      1. Dosing recommended in Status Epilepticus is higher
        1. Load: 20 to 40 mg/kg IV (up to 3000 mg/dose)
          1. Infuse slowly (no faster than 6 mg/kg/min)
        2. Maintain: 5 mg/kg/hour or 4 to 8 mg/kg IV three times daily (adjusting based on serum levels)
      2. Adverse effects
        1. Less sedation, respiratory depression, and cardiovascular effects than any of the other agents
        2. Risk of hepatotoxicity
        3. Risk of hyperammonemia (avoid in age under 2 years, especially if inborn error of metabolism)
  4. Next (if refractory after 30 minutes)
    1. Phenobarbital (less commonly used in 2020 - used if second line options not available or Neonatal Seizure)
      1. Dose: 15 to 20 mg/kg IV
        1. May repeat twice with Phenobarbital 5-10 mg/kg IV
        2. Maximal infusion rate: 0.5 to 1 mg/kg/minute
      2. Pharmacokinetics: Onset within 10-20 minutes and duration of 1-3 days
      3. Be prepared to ventilate patient
      4. More effective than Phenytoin as a second line agent in pediatric Seizure
        1. Burman (2019) Front Neurol 10:506 [PubMed]
  5. Next (if refractory after 60 minutes)
    1. Preparation
      1. Requires full life support (coma state)
        1. Intubate and ventilate
        2. Rapid Sequence Intubation
          1. Consider Pentobarbital, Benzodiazepines, Ketamine or Propofol for induction agent
          2. Paralytic is recommended for RSI despite the masking of Seizure activity
            1. Use Rocuronium despite long Half-Life if Hyperkalemia cannot be excluded
      2. Foley Catheter
      3. Electroencephalogram (EEG)
        1. Dosages below titrated based on EEG
        2. Infusion slowed every 4-6 hours to check EEG status
      4. Follow Temperature closely
        1. Treat hyperthermia with rectal Acetaminophen 15 mg/kg up to 650-1000 mg every 6 hours
      5. Pressor support
        1. Often required for next set of medictions
    2. Choose one medication (combined post-intubation sedation AND antiepileptic)
      1. See Phenobarbital as above
      2. Propofol (Diprivan)
        1. Load: 1 to 2 mg/kg IV
          1. May repeat every 5 min as needed to total max of 10 mg/kg
        2. Maintain: 30 to 50 mcg/kg/min (2-10 mg/kg/hour) IV infusion
          1. Indicated if Propofol loading dose aborted the Seizure
        3. Anticipate apnea and Hypotension with rapid infusion
        4. Risk of Propofol Infusion Syndrome (esp. children)
          1. Catastrophic outcomes with use >48 hours, esp. at high dose (e.g. 10 mg/kg/h)
          2. Do not use Propofol for extended time, especially in children
          3. Lower risk of Propofol Infusion Syndrome with doses <5 mg/kg/hour
      3. Pentobarbital (Nembutal)
        1. Load: 5 mg/kg IV (up to 15 mg/kg, coma dose)
        2. Maintain: 0.5 to 1 mg/kg/hour (up to 5 mg/kg/hour)
        3. Anticipate myocardial depression with secondary reduced Cardiac Output and Hypotension
      4. Midazolam (Versed)
        1. Load: 0.2 mg/kg IV
          1. May repeat every 5 min to maximum total of 2 mg/kg
        2. Maintain: 1 mcg/kg/min (0.2 to 2.9 mg/kg/hour) infusion
        3. Titrate: Increase by 1 mcg/kg/min every 15 minutes until burst suppression (up to 0.75 to 10 mg/hour)
        4. Anticipate respiratory depression
      5. Ketamine (alternative agent, Pentobarbital, Midazolam, Propofol are preferred)
        1. Antagonizes NMDA receptors and AMPA receptors
        2. Dose: 1.5 to 2 mg/kg
        3. If Ketamine aborts Seizure, then start Propofol maintenance at dose as above
        4. Case reports of neurotoxicity in adults

XIV. Prognosis

  1. Mortality
    1. Overall: 22%
    2. Children: 3%
    3. Adults: 26%
    4. Elderly: 38%
    5. DeLorenzo (1996) Neurology 46:1026-35 [PubMed]
  2. Morbidity
    1. High Incidence of neurologic sequelae
    2. Worse outcomes with longer duration of Seizure

XV. Complications: Prolonged Seizure

  1. Anoxic brain injury
  2. Death
  3. Rhabdomyolysis (after 30-60 minutes of Seizure)
  4. Hypoglycemia
  5. Metabolic Acidosis
  6. Aspiration

XVI. References

  1. Fuchs and Yamamoto (2012) APLS, Jones and Bartlett, Burlington, p. 191-7
  2. Lu, Claudius and Behar in Herbert (2013) EM:Rap 13(12): 12-3
  3. Morgenstern in Herbert (2020) EM:Rap 20(10):12-4
  4. Nocera, Valente, Amanullah (2018) Crit Dec Emerg Med 32(11): 3-9
  5. Piner and Chang (2025) Crit Dec Emerg Med 39(2): 4-12
  6. (1993) JAMA 270:854-9 [PubMed]
  7. Abend (2008) Pediatr Neurol 38(6): 277-390 [PubMed]
  8. Glauser (2016) Epilepsy Currents 16(1): 48-61 [PubMed]
  9. Hanhan (2001) Pediatr Clin North Am 48(3): 1-12 [PubMed]
  10. Lowenstein (1998) N Engl J Med 338:970-6 [PubMed]
  11. Sirven (2003) Am Fam Physician 68(3):469-76 [PubMed]

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Related Studies

Ontology: Status Epilepticus (C0038220)

Definition (NCI) A life-threatening situation in which the brain is in a continuous state of seizure.
Definition (MSH) A prolonged seizure or seizures repeated frequently enough to prevent recovery between episodes occurring over a period of 20-30 minutes. The most common subtype is generalized tonic-clonic status epilepticus, a potentially fatal condition associated with neuronal injury and respiratory and metabolic dysfunction. Nonconvulsive forms include petit mal status and complex partial status, which may manifest as behavioral disturbances. Simple partial status epilepticus consists of persistent motor, sensory, or autonomic seizures that do not impair cognition (see also EPILEPSIA PARTIALIS CONTINUA). Subclinical status epilepticus generally refers to seizures occurring in an unresponsive or comatose individual in the absence of overt signs of seizure activity. (From N Engl J Med 1998 Apr 2;338(14):970-6; Neurologia 1997 Dec;12 Suppl 6:25-30)
Concepts Disease or Syndrome (T047)
MSH D013226
ICD10 G41 , G41.9
SnomedCT 194499008, 193019007, 155039002, 192998006, 13973009, 230456007
English STATUS EPILEPTICUS, Status epilepticus, unspec, Status epilepticus, unspecified, [X]Status epilepticus, unspec, [X]Status epilepticus, unspecified, Generalized Status Epilepticus, Status Epilepticus, Generalized, Status Epilepticus [Disease/Finding], status epilepticus, epilepticus status, [X]Status epilepticus, unspecified (disorder), Status epilepticus, Status epilepticus (disorder), epilepsy; status, epilepticus; status, status; epilepticus, status; epileptic, Status epilepticus NOS, Status Epilepticus
German STATUS EPILEPTICUS, Status epilepticus, nicht naeher bezeichnet, Status epilepticus
Italian Stato epilettico, Stato epilettico generalizzato, Status epilepticus
Swedish Status epilepticus
Japanese ﾃﾝｶﾝｼﾞｭｳｾｷｼﾞｮｳﾀｲ, 癲癇重積状態, 癲癇重積症, てんかん発作重積, 発作重積状態, 小発作状態, てんかん重積, てんかん重積状態, 小発作重積状態
Czech status epilepticus, Status epilepticus
Finnish Epileptinen sarjakohtaus
Russian PETIT MAL, STATUS, EPILEPTICHESKII STATUS, PETIT MAL, СТАТУС, ЭПИЛЕПТИЧЕСКИЙ СТАТУС
Portuguese ESTADO DE MAL EPILEPTICO, Estado Epilético Parcial Simples, Estado Epilético não Convulsivo, Estado Epilético Convulsivo Generalizado, Estado Epilético Parcial Complexo, Estado de mal epiléptico, Estado Epiléptico
Spanish ESTADO EPILEPTICO O STATUS EPILEP, [X]estado epiléptico, no especificado (trastorno), [X]estado epiléptico, no especificado, Estatus epiléptico, estado epiléptico, estado epiléptico (trastorno), Estado Epiléptico
French ETAT DE MAL EPILEPTIQUE, Etat de mal épileptique, État de mal épileptique
Korean 상세불명의 간질 지속상태, 간질 지속상태
Polish Stan padaczkowy
Hungarian Status epileptikus
Norwegian Status epilepticus, Generalisert status epilepticus
Dutch epilepsie; status, epilepticus; status, status; epilepsie, status; epilepticus, Status epilepticus, niet gespecificeerd, status epilepticus, Status epilepticus, Complexe partiële status epilepticus
Derived from the NIH UMLS (Unified Medical Language System)

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