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Status Epilepticus


  • Either a single seizure >5 minutes or ≥ 2 seizures occurring without a return to baseline in between
  • Differentiating convulsive seizures from non-epileptic events (“pseudoseizure”):
    • Features that suggest non-epileptic/psychogenic event include moaning or talking throughout the event, “no-no” head shake, repetitive movements of opposing muscle groups, very arrhythmic or purposeful-looking movements, or seizures that have been ongoing for “hours”


  • Fingerstick glucose, BMP/CBC, and UDS
  • Consult Neurology
  • EEG (start with 2hr) to determine if it is seizure or not and for titration of medications
  • Consider a non-contrasted head CT; MRI cannot be obtained while EEG is attached
  • Up to half of pts presenting in status epilepticus have no history of seizure, so they need urgent head imaging, consideration for lumbar puncture, infectious and toxic workup, tox screen, and sometimes rheumatologic or paraneoplastic workup
  • If HX of seizure or on Antiseizure meds (ASMs) please order trough levels


  • ABCs! Start with benzos:

    • 2 mg lorazepam IV then repeat q1-3 minutes up to 0.1 mg/kg OR

    • 5 mg of diazepam IV every minute (takes longer to give diazepam so would give concurrent ASM)

    • 10 mg IM midazolam if no IV access

  • After 2 rounds of benzos, would shift to antiepileptics if still in status (neurology should be contacted here if not already):

    • IV fosphenytoin 20 mg/kg

    • IV levetiracetam 60 mg/kg (up to 4.5g max)

    • IV valproic acid 40 mg/kg

  • If still seizing at this point, the patient will likely need intubation

  • These pts MUST be placed on EEG if they get paralyzed or sedated because convulsive status often continues as nonconvulsive status, which still damages the brain!

    • If still seizing, patients should be on midazolam, propofol or barbiturate infusions

    • Focal seizures, such as arm or face twitching with retained awareness do not always need to be treated to the point of initiating coma