Status epilepticus: stop the seizure.
Status epilepticus from minute zero: treat at 5 minutes, one full benzodiazepine dose, one full second-line load, the causes to treat in parallel, continuous EEG for the patient who doesn't wake, anesthetic infusions for refractory status, and discharge counseling.
Reviewed October 2026 · verify against current guidelines
Two clocks, not one.
A convulsive seizure lasting 5 minutes is status epilepticus (SE). The ILAE sets two time points: t1, when to start treatment, and t2, when ongoing seizure risks lasting injury (Trinka 2015).
ILAE time points: t1 treat · t2 injury
| Convulsive (tonic-clonic) | Treat at 5 min · injury risk at 30 min |
|---|---|
| Focal, impaired awareness | Treat at 10 min · injury risk beyond 60 min |
| Absence | Treat at 10 to 15 min · injury risk unknown |
AES 2016 timeline, convulsive SE (minutes from onset)
| 0 to 5 | Stabilize: airway, oxygen, ECG, fingerstick glucose, IV access, labs. |
|---|---|
| 5 to 20 | Initial therapy: a benzodiazepine. |
| 20 to 40 | Second therapy: one IV antiseizure drug, as a single full load. |
| 40 to 60 | Third therapy: repeat second-line, or anesthetic doses with continuous EEG. |
One full dose, first time.
Give a benzodiazepine at 5 minutes as a single weight-based dose, not split into small aliquots (AES 2016).
Benzodiazepines
| Midazolam IM (no IV) | 10 mg if over 40 kg (5 mg if 13 to 40 kg). Single dose (AES 2016; RAMPART). |
|---|---|
| Lorazepam IV | 0.1 mg/kg, max 4 mg per dose. Repeat once if still seizing. |
| Diazepam IV | 0.15 to 0.2 mg/kg, max 10 mg per dose. Repeat once if still seizing. |
AES 2016 rates the evidence for all three as level A (IV phenobarbital is level A too). Only lorazepam and diazepam are repeated. AES 2016 is under revision; ACEP 2024 rates levetiracetam, fosphenytoin and valproate as similarly effective second-line options (level A).
The trials
| RAMPART, 2012 · n = 893 | Prehospital, no IV in place. IM midazolam 10 mg stopped seizures before emergency department arrival in 73%, IV lorazepam 4 mg in 63%. IM took a median 1.2 min to give, IV 4.8 min. |
|---|---|
| ESETT dosing · n = 460 | The first dose was below guideline in 81% of midazolam and 76% of lorazepam administrations. Median time from onset to first benzodiazepine: 27 min. |
Load one, fully.
Still seizing after the benzodiazepine: give one of three IV loads, each over 10 min. In ESETT, none outperformed the others.
IV loads, each over 10 min (stopped = ESETT response)
| Levetiracetam | 60 mg/kg, max 4,500 mg. Stopped 47%. |
|---|---|
| Fosphenytoin | 20 mg PE/kg, max 1,500 mg PE. Stopped 45%. |
| Valproate | 40 mg/kg, max 3,000 mg. Stopped 46%. |
| Phenobarbital | 15 mg/kg, single dose. Not tested in ESETT. |
- Fosphenytoin: no faster than 150 mg PE/min. Monitor ECG and blood pressure for hypotension and arrhythmia (US label).
- Valproate: avoid in pregnancy and liver disease; boxed warnings for hepatotoxicity, fetal risk and pancreatitis (US label).
- Phenobarbital: fallback if none of the three is available (AES 2016). Not part of ESETT.
- AES 2016: give the second therapy as a single full dose. Where both are stocked, fosphenytoin is preferred over phenytoin for tolerability.
ESETT, 2019 · n = 384 — children and adults with benzodiazepine-refractory convulsive status in 57 US emergency departments. Stopped means no clinical seizures and improving responsiveness at 60 min without another drug. Median time to seizure stop among responders: 7 to 12 min.
Treat the cause in parallel.
Antiseizure drugs will not hold if the trigger persists. Send the workup with the first dose (NCS 2012).
Every patient
- Fingerstick glucose.
- CBC, BMP, calcium, magnesium.
- Head CT in most cases.
- Continuous EEG.
- Drug levels if on antiseizure medication.
By presentation
- MRI brain.
- Lumbar puncture.
- Toxicology: isoniazid, TCAs, theophylline, cocaine.
- Pregnancy test, anyone of childbearing age.
Causes with their own treatment
| Hypoglycemia | Glucose below 60 mg/dL: thiamine 100 mg IV, then 50 mL D50W IV (AES 2016). |
|---|---|
| Hyponatremia | 3% saline 100 mL IV boluses, repeated as needed. |
| Eclampsia | Magnesium sulfate 4 to 6 g IV over about 15 min, then an infusion. Treat blood pressure in parallel. |
| Isoniazid | Pyridoxine 1 g per gram of isoniazid ingested; 5 g if the amount is unknown. Infuse at 0.5 g/min until seizures stop; doses can be repeated (poison center guidance). |
Stopped moving is not stopped seizing.
Seizures can continue on EEG after convulsions end: nonconvulsive status epilepticus (NCSE). A useful rule: a patient who is not waking has NCSE until EEG shows otherwise (teaching heuristic; NCS lists suspected nonconvulsive seizures with altered mental status as a cEEG indication).
Get continuous EEG (cEEG) for
- No return to baseline more than 10 min after a seizure or SE.
- Coma, including after cardiac arrest.
- Epileptiform or periodic discharges on a first 30-min EEG.
- Intracranial hemorrhage: TBI, SAH, ICH.
- Altered mental status with suspected nonconvulsive seizures.
| Within 1 h | Start cEEG within an hour of SE onset if ongoing seizures are suspected. |
|---|---|
| 48 h or more | Monitor comatose patients for at least 48 hours to catch nonconvulsive seizures (NCS 2012). |
No EEG yet? Expose the patient and watch the eyes and small muscles: gaze deviation, nystagmus, blinking, subtle facial or limb twitching.
When two drugs fail.
Refractory SE: seizures continue after a benzodiazepine and one IV antiseizure drug. Intubate and start a continuous infusion, titrated to EEG (NCS 2012).
Infusions (NCS 2012 refractory SE table)
| Midazolam | Load 0.2 mg/kg; breakthrough 0.1 to 0.2 mg/kg bolus. Infusion 0.05 to 2 mg/kg/h, raised 0.05 to 0.1 mg/kg/h every 3 to 4 h. |
|---|---|
| Propofol | Load 1 to 2 mg/kg (hypotension, worst with the load). Infusion 30 to 200 mcg/kg/min; start at 20 mcg/kg/min. |
| Pentobarbital | Load 5 to 15 mg/kg, extra 5 to 10 mg/kg if needed. Infusion 0.5 to 5 mg/kg/h. Hypotension; requires ventilation. |
Titrate and wean
| Target | Seizure cessation on EEG, or burst suppression. |
|---|---|
| Hold | 24 to 48 h of electrographic control, then withdraw the infusion slowly, on cEEG. |
| Before | Maintenance antiseizure drugs in place. Rebound seizures follow a fast wean or a missing maintenance drug. |
Beyond 24 hours.
Super-refractory SE (SRSE): seizures continue or recur 24 h or more after anesthesia starts, including on weaning.
| NORSE | New-onset refractory status epilepticus: refractory SE without active epilepsy and without a clear acute structural, toxic or metabolic cause. |
|---|---|
| FIRES | Febrile infection-related epilepsy syndrome: NORSE preceded by a febrile infection 2 weeks to 24 h before onset (Hirsch 2018). |
| Ketamine | 68 SRSE patients: seizures stopped within 24 h in 63%, mean infusion 2.2 mg/kg/h. Retrospective study, class IV evidence (Alkhachroum 2020). |
| Immunotherapy | Neurology-led, even with negative serology: methylprednisolone 1 g/day for 3 days, IV immunoglobulin or plasma exchange (Mullhi 2025). |
Before they go home.
Discharge counseling after status epilepticus in a patient with epilepsy: SUDEP, a rescue plan and everyday safety.
SUDEP (sudden unexpected death in epilepsy)
| 1 in 1,000 | Adults with epilepsy each year. |
|---|---|
| 15× | Risk with 3 or more tonic-clonic seizures a year. |
| 18 per 1,000 | Deaths a year, upper estimate with frequent tonic-clonic seizures (AAN/AES 2017). |
Clinicians should tell adults with epilepsy that the risk is small. Fewer tonic-clonic seizures is the main lever; seizures during sleep may add risk (AES 2019).
Cover before discharge
| Rescue plan | A written seizure action plan. Nasal midazolam (age 12+) and nasal diazepam (age 2+ since 2025) are FDA-approved for seizure clusters at home. |
|---|---|
| Driving | State law sets a seizure-free period, typically 3 to 12 months. The state licensing agency decides, usually based on the treating doctor's assessment; only a few states require doctors to report. |
| Water | Showers, not baths. Swim only with someone who can respond to a seizure, and wear a life jacket. |
Educational reference only — not medical advice. Verify against local protocol.
Sources
Verify against current guidelines and local protocol before acting.
- Trinka E, et al. ILAE definition and classification of status epilepticus. Epilepsia 2015;56:1515–23.
- Glauser T, et al. AES guideline: treatment of convulsive status epilepticus. Epilepsy Curr 2016;16:48–61.
- Silbergleit R, et al. RAMPART. N Engl J Med 2012;366:591–600.
- Sathe AG, et al. Benzodiazepine underdosing in ESETT. Epilepsia 2021;62:795–806.
- Kapur J, et al. ESETT. N Engl J Med 2019;381:2103–13.
- Brophy GM, et al. Neurocritical Care Society guideline for status epilepticus. Neurocrit Care 2012;17:3–23.
- Mullhi R, et al. Acute management of status epilepticus in adults. J Intensive Care Soc 2025;26:249–62.
- Helman A, Gray S. Update in management of status epilepticus. Emergency Medicine Cases, episode 213, February 2026.
- Maryland Poison Center. Antidote facts: pyridoxine.
- Hirsch LJ, et al. Definitions for NORSE and FIRES. Epilepsia 2018;59:739–44.
- Alkhachroum A, et al. Ketamine for super-refractory status epilepticus. Neurology 2020;95:e2286–94.
- ACEP clinical policy: seizures and status epilepticus, 2024.
- Harden C, et al. AAN/AES practice guideline: SUDEP incidence rates and risk factors. Neurology 2017;88:1674–80.
- AES position statement on SUDEP counseling, 2019.
- Epilepsy Foundation. Staying safe; nasal rescue medicines.
- Treiman DM, et al. VA Cooperative trial, four treatments for convulsive status epilepticus. N Engl J Med 1998;339:792–8.
- Fosphenytoin sodium injection, US prescribing information (DailyMed).
- Valproate, US prescribing information (DailyMed).
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