Status Epilepticus (Adult and Pediatric)

Status epilepticus is a seizure whose brakes have failed, or one that something has switched on and won't let go. The ILAE 2015 definition gives convulsive status two clocks. At 5 minutes (t1), a seizure counts as status. Past 30 minutes (t2), ongoing activity carries a risk of neuronal death and long-term injury. Those two clocks are why timing matters.

• Convulsive status: generalized tonic-clonic activity, or focal motor activity that persists or recurs without recovery of consciousness
• Non-convulsive status: persistent altered awareness, staring, eye or facial twitching, or subtle automatisms, with ongoing seizure activity on EEG. Think of it when the patient won't climb back to baseline after a convulsion
• Common causes: antiseizure drug withdrawal or nonadherence, acute brain injury (stroke, trauma, hemorrhage, CNS infection), metabolic derangement (hypoglycemia, hypoxia, hyponatremia), alcohol or drug withdrawal, and toxin exposure such as isoniazid (treat with pyridoxine), local anesthetics, and sympathomimetic or anticholinergic agents
• Benzodiazepine-refractory status: seizures that continue after an adequate benzodiazepine dose. Each delay makes the outcome worse, so you escalate by stage. Don't sit and wait

Convulsive Status

• Continuous convulsions for 5 minutes or longer, or repeated seizures without return to baseline between them
• Clock start: the first seizure activity you see or are told about. Write down the onset time. Every later time point hangs off it

Red Flags

• SpO₂ falling, apnea, or cyanosis during or after the seizure (airway and breathing compromise)
• Hypotension, bradycardia or an arrhythmia on the monitor
• Glucose low or unknown in a patient with altered mental status
• Fever or hyperthermia, which adds to brain injury
• Pregnancy, or seizure in the 6 weeks after delivery (treat as eclampsia; see Special Populations)

Treat first, and assess at the same time. The work-up finds the cause and checks for the drug, breathing and metabolic problems you can fix at the bedside.

EEG confirms the diagnosis when the patient is paralyzed, won't come back to baseline after treatment, or the event is uncertain. Neuroimaging and the search for a cause come once the patient is stable.

• Psychogenic nonepileptic seizures: long events with eyes closed, movements that wax and wane, or resistance to eye opening make you suspicious. ESETT found about 10% of enrolled patients had psychogenic seizures. Confirm it before escalating to intensive care.
• Syncope with convulsive movements: usually brief, with pallor, sweating or a prodrome beforehand and a rapid return to baseline
• Toxic or metabolic encephalopathy: confusion or myoclonus without a clear seizure pattern. Check glucose, sodium and toxins
• Hypertensive emergency or eclampsia: seizure with severe hypertension. In pregnancy, eclampsia comes first

1. Protect from injury: clear the area and cushion the head. Do not restrain. Do not put anything in the mouth.
2. Time the seizure from onset and tell ALS when treatment is due at 5 minutes.
3. Position on the side (recovery position) once the convulsion stops or if vomiting occurs. Suction the airway as needed.
4. Oxygen at high flow. Use a bag-valve mask if breathing is inadequate or SpO₂ falls.
5. Check glucose if it is within your scope and protocol.
6. Call for ALS early for any seizure lasting 5 minutes or longer, or repeated seizures without recovery. Report onset time, duration, drugs given and response.

Doses vary by protocol; follow local protocols and medical direction. Adults and children run the same pathway. Give the first benzodiazepine the moment the seizure hits 5 minutes. Don't wait for IV access.

• First-line benzodiazepine, adult (Paramedic/RN/CCT): midazolam 10 mg IM once (adults over 40 kg, RAMPART dosing) into the mid-outer thigh. The 10 mg autoinjector is FDA-labeled for status epilepticus in adults. Midazolam can block the airway and slow breathing. See Midazolam
• First-line benzodiazepine, IV access (Paramedic/RN/CCT): lorazepam 4 mg IV slowly at no more than 2 mg/min for adults 18 years and older. If seizures continue or recur after 10 to 15 minutes, repeat 4 mg IV once. Contraindicated in sleep apnea syndrome, severe respiratory insufficiency (except when ventilated) and acute narrow-angle glaucoma. See Lorazepam
• Alternative IV benzodiazepine (Paramedic/RN/CCT): diazepam 5 to 10 mg IV slowly (label: at least 1 minute per 5 mg), repeated every 10 to 15 minutes to a maximum of 30 mg (FDA label). Contraindicated in acute narrow-angle glaucoma. Many protocols use weight-based dosing instead. See Diazepam
• Pediatric benzodiazepine (Paramedic/RN/CCT): diazepam 0.2 mg/kg IV by slow push over 1 minute (max 8 mg), then 0.1 mg/kg (max 4 mg) 5 minutes later if still seizing (FDA label, ages 3 months to 17 years). Lorazepam 0.1 mg/kg IV (max 4 mg per dose) as used in the pediatric trial; the lorazepam label gives no pediatric status epilepticus dose. IM midazolam: 10 mg for children over 40 kg and 5 mg for 13 to 40 kg (RAMPART dosing); under 13 kg per protocol. Intranasal, buccal and rectal options are AES Level B alternatives when IV access is not available; doses are protocol-specific. See Weight-Based Dosing
• Second-line drug, if still seizing after an adequate benzodiazepine dose (Paramedic/RN/CCT): levetiracetam 60 mg/kg IV over 10 minutes (max 4,500 mg); fosphenytoin 20 mg PE/kg IV (label range 15 to 20 mg PE/kg) at no more than 150 mg PE/min in adults, or no more than 2 mg PE/kg/min or 150 mg PE/min, whichever is slower, in children (max 1,500 mg PE). Do not give fosphenytoin or phenytoin with sinus bradycardia, sino-atrial block, second- or third-degree AV block or Adams-Stokes syndrome, or with delavirdine; choose a non-phenytoin option per protocol. Phenytoin, when fosphenytoin is unavailable: adults 10 to 15 mg/kg IV at no more than 50 mg/min; children 15 to 20 mg/kg at no more than 1 to 3 mg/kg/min or 50 mg/min, whichever is slower. Both can cause purple glove syndrome. Levetiracetam and fosphenytoin are not the first drug in active status. See Levetiracetam and Fosphenytoin
• Other second-line options (per protocol): IV phenobarbital is an AES Level A initial alternative to benzodiazepines when no benzodiazepine is available, and an AES Level B second-line option; dose per protocol. Valproate is an ESETT second-line option at 40 mg/kg IV (max 3,000 mg); it is not FDA-labeled for status epilepticus, and its boxed warnings cover fetal risk, hepatotoxicity (highest under 2 years) and POLG mitochondrial disease; avoid in pregnancy and hepatic disease. See Phenobarbital
• Airway (Paramedic/RN/CCT): bag-valve mask first. Advanced airway if the patient cannot protect the airway, SpO₂ stays low, or seizures continue after second-line therapy. See RSI
• Monitoring: continuous SpO₂, EtCO₂, cardiac monitor and frequent blood pressure during and after every benzodiazepine or second-line dose.

In the ESETT trial, each second-line agent stopped seizures in about half of patients, and no one agent beat the others significantly. Choose by the patient's medications and side-effect profile, and by local protocol.

• Refractory status: Seizures that outlast an adequate benzodiazepine and a second-line drug. Escalate to ICU care with continuous EEG, airway control and an anesthetic infusion per the neurocritical care protocol. Infusion agents include propofol and midazolam infusions; doses are protocol-specific. Third-line agents are the neurocritical care team's call, per protocol.
• Intubation: Plan early for any patient who needs an infusion or whose carbon dioxide is rising. Use RSI, and have the post-intubation sedation plan ready.
• Diagnosis: continuous EEG to confirm seizure control in paralyzed or sedated patients, plus neuroimaging and a search for the cause (stroke, CNS infection, hypoglycemia, toxins, withdrawal).
• Consults: Call neurology or neurocritical care early for any patient who doesn't respond to the first two drug classes.
• Disposition: ICU admission for refractory status or any patient who needed an infusion or intubation.

• Destination: a neurology-capable emergency department or a center with neurocritical care, per local protocol. Don't hold transport to find a bed for a patient who is still seizing.
• Keep monitoring in transit: continuous SpO₂ and EtCO₂, cardiac monitor, and airway equipment within reach. Benzodiazepines can cause apnea after the seizure stops. The sedation can hide a recurrence.
• Fosphenytoin timing: At 150 mg PE/min in an adult, a 1,500 mg PE load takes 10 minutes. Children run slower by weight (2 mg PE/kg/min or 150 mg PE/min, whichever is slower). Start it early enough to finish in transport or on arrival.
• Do not give flumazenil: Flumazenil is contraindicated here. That covers any benzodiazepine given for a life-threatening condition such as status epilepticus (flumazenil and benzodiazepine labels).
• Handoff: seizure onset time and duration, each benzodiazepine and second-line dose with its time and route, glucose, airway status and response.

• Pediatrics: Kids get the same 5-minute trigger. Lorazepam and diazepam IV are established for children (AES Level A). IM midazolam is probably effective in kids (AES Level B). Use weight-based dosing and pediatric vital signs. Second-line dosing is weight-based per protocol, and the ESETT trial enrolled children as well as adults. Valproate is avoided under 2 years (see ALS). Neonatal seizures are a specialist pathway. Don't apply this adult algorithm without neonatal or neurology input.
• Pregnancy: A seizure in pregnancy, or up to 6 weeks postpartum with no other cause, is eclampsia until shown otherwise. Give magnesium sulfate first (4 to 6 g IV over 20 to 30 minutes, then 1 to 2 g/hr; see Magnesium Sulfate), then follow the obstetric protocol. Benzodiazepines are still the first-line class for status epilepticus. Second-line choice is made with obstetric and neurology input.
• Older Adults: No separate status epilepticus dose is labeled. Watch for respiratory depression from benzodiazepines. Watch for hypotension and arrhythmia during the fosphenytoin infusion.
• Renal Impairment: Levetiracetam leaves the body through the kidneys, so its label adjusts maintenance dosing for kidney function. No other status epilepticus adjustment is established for the drugs on this page.
• Obesity: Dose weight-based drugs on actual body weight, up to their maximum. Levetiracetam and fosphenytoin hit their maximums at 75 kg (4,500 mg ÷ 60 mg/kg; 1,500 mg PE ÷ 20 mg PE/kg). Heavier patients get the capped dose.

• Error: Holding the benzodiazepine until IV access is in. At 5 minutes, give IM midazolam 10 mg (adults over 40 kg) instead.
• Error: Running fosphenytoin faster than the label allows: 150 mg PE/min in adults, and 2 mg PE/kg/min or 150 mg PE/min, whichever is slower, in children. The boxed warning cites severe hypotension and arrhythmia. Dose in mg PE, not mg of phenytoin. Run it on cardiac monitoring, and expect the BP to be checked during the infusion.
• Error: Fosphenytoin or phenytoin in a patient with sinus bradycardia, sino-atrial block, second- or third-degree AV block, Adams-Stokes syndrome, prior hepatotoxicity from phenytoin, or one who takes delavirdine. Those are labeled contraindications. Choose another drug per protocol.
• Error: A benzodiazepine stacked on an opioid or other sedative, with no plan to ventilate. The boxed warning cites profound sedation, respiratory depression, coma and death. Support the airway and reassess breathing after each dose.
• Error: Mixing up diazepam doses. The adult FDA label gives 5 to 10 mg IV, with a maximum of 30 mg. The pediatric label regimen (ages 3 months to 17 years) is 0.2 mg/kg (max 8 mg), then 0.1 mg/kg (max 4 mg) 5 minutes later. Many protocols use 0.15 to 0.2 mg/kg (max 10 mg). Use one set per protocol, and document it.
• Error: Lorazepam in a premature infant. The label contraindicates it because of benzyl alcohol.
• Error: Flumazenil after a benzodiazepine for status epilepticus. It is contraindicated (flumazenil and benzodiazepine labels), and it can bring on seizures.
• Error: Calling a patient who stopped convulsing recovered. Persistent altered awareness after a seizure needs a second look for ongoing seizure activity.
• Error: Reading a neuromuscular blocker or sedation as seizure control. Paralysis hides ongoing seizures. Confirm with EEG when a paralytic is used.