Neuro emergencies

Status epilepticus ladder

Reviewed Nov 2026·3 references
New· views rounded down, updated weekly

Seizure > 5 min or recurrent without recovery: adequate-dose benzodiazepine by 5-10 min, a second-line agent (levetiracetam, valproate or phenytoin, all equivalent in ESETT) by 20-30 min, then anaesthetic infusion with EEG for refractory status.

Definition
Convulsive status: ≥ 5 min of continuous seizure or ≥ 2 seizures without return to baseline. Refractory: continues after a benzodiazepine and one second-line drug. Super-refractory: continues ≥ 24 h after anaesthesia.

At the bedside

Timed steps
  1. 1

    Stabilise

    0-5 min

    ABC, oxygen, glucose (give thiamine then dextrose if < 60 mg/dL), IV access, time the seizure.

  2. 2

    Benzodiazepine

    5-10 min

    Lorazepam 0.1 mg/kg IV (max 4 mg), repeat once; or midazolam 10 mg IM; or diazepam 0.15-0.2 mg/kg IV (max 10 mg). Give the full dose.

  3. 3

    Second line

    10-30 min

    Levetiracetam 60 mg/kg (max 4.5 g) or valproate 40 mg/kg (max 3 g) or phenytoin 20 mg/kg (fosphenytoin 20 mg PE/kg). ESETT: ~half stopped with each; no drug superior.

  4. 4

    Refractory

    30-60 min

    Intubate; midazolam 0.2 mg/kg then 0.05-2 mg/kg/h, or propofol 1-2 mg/kg then 20-200 mcg/kg/min (watch PRIS), or ketamine. Continuous EEG; titrate to seizure suppression or burst suppression for 24-48 h.

  5. 5

    Search

    Cause

    Glucose, Na+, Ca2+, Mg2+, drug levels/toxicology, CT then MRI, LP if infection possible; eclampsia (magnesium), TB/neurocysticercosis, autoimmune encephalitis.

  6. 6

    Non-convulsive SE

    After

    No return of consciousness 10-20 min after movements stop: EEG to exclude non-convulsive status.

First line

Lorazepam

IV
Dose
0.1 mg/kg (max 4 mg), repeat once at 5-10 min
Worked example
70 kg: 4 mg IV, repeat 4 mg if still seizing

Second line

Levetiracetam

IV over 10-15 min
Dose
60 mg/kg, max 4500 mg
Worked example
60 kg: 3600 mg in 100 mL 0.9% saline over 15 min

Second line

Phenytoin

IV in saline
Dose
20 mg/kg at ≤ 50 mg/min
Worked example
70 kg: 1400 mg over ≥ 28 min

Refractory SE infusion

Midazolam

IV
Dose
0.2 mg/kg bolus, then 0.05-2 mg/kg/h
Range
0.05–2 mg/kg/h
Red flag · call your senior now
Persisting coma after convulsions stop: non-convulsive status until EEG says otherwise.
Red flag
Pregnant or post-partum woman with seizures: eclampsia; give magnesium sulphate.
Pitfall
Under-dosed benzodiazepines (e.g. 2 mg lorazepam for 80 kg) and delayed second-line therapy.
Pitfall
Valproate with meropenem (levels collapse).
Pitfall
Phenytoin given too fast or in dextrose.
Pearl
Neurocysticercosis is a leading cause of new-onset seizures in Indian adults; TB and stroke are also common.

References

  1. 1

    Glauser T, Shinnar S, Gloss D, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61

  2. 2

    Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17(1):3-23

  3. 3

    Kapur J, Elm J, Chamberlain JM, et al. Randomized trial of three anticonvulsant medications for status epilepticus (ESETT). N Engl J Med. 2019;381(22):2103-2113

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