Status epilepticus - Revision history

Danbot: Strip excess bold text - keep only critical safety emphasis

2026-03-22T09:23:04Z

Strip excess bold text - keep only critical safety emphasis

Danbot: Major expansion: time-based protocol, RAMPART/ESETT references, special situations, refractory management

2026-03-21T18:31:16Z

Major expansion: time-based protocol, RAMPART/ESETT references, special situations, refractory management

← Revisión anterior		Revisión del 18:31 21 mar 2026
Línea 1:		Línea 1:
	~~{{AdultPage\|Status epilepticus (peds)}}~~
	==Background==		==Background==
	*~~Definitions have varied~~, ~~but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments~~ or ~~recurrent seizure activity~~ without return to baseline ~~mental status.~~<ref>~~Epilepsy Foundation of America~~. ~~Treatment~~ of ~~convulsive~~ status epilepticus. ~~Recommendations~~ of the ~~Epilepsy Foundation of America~~'~~s Working Group on Status Epilepticus~~. ~~JAMA. 1993 Aug 18. 270~~(7):~~854~~-9</ref>~~<ref>Lowenstein DH, Cloyd J. Out~~-of-~~hospital treatment of status epilepticus~~ and ~~prolonged~~ seizures~~. Epilepsia. 2007. 48 Suppl 8:96~~-~~8</ref> (Previous definitions used a 30~~-~~minute time limit)<ref>Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4)~~:~~592.</ref~~>		*Continuous seizure activity lasting >5 minutes, or ≥2 seizures without return to baseline<ref name="trinka">Trinka E, et al. A definition and classification of status epilepticus. Report of the ILAE Task Force. ''Epilepsia''. 2015;56(10):1515-1523. PMID 26336950.</ref>
	*~~Overall mortality is high~~ (~~22%~~)~~<ref name="Martindale">Martindale JL, Goldstein JN, Pallin DJ. Emergency department seizure epidemiology. Emerg Med Clin North Am. 2011 Feb;29~~(1)~~:15-27.</ref>~~		*'''Time-sensitive emergency''' — mortality increases with duration of seizure
	*~~Divided in generalized convulsive status epilepticus~~ (~~GCSE) and nonconvulsive status epilepticus (NCSE~~)		*30-day mortality: 20% overall; higher in elderly and those with anoxic injury
	**~~NCSE presents as an alteration in behavior associated with subtle changes (as twitching~~, ~~blinking~~, ~~eye deviation~~, ~~aphasia~~, ~~somatosensory findings~~) ~~and continuous epileptiform discharges on EEG~~		*Refractory SE: seizures persisting despite two appropriate first-line agents
			*Super-refractory SE: seizures persisting >24 hours despite anesthetic agents

			==Etiology==
			*Anti-epileptic drug (AED) non-compliance or subtherapeutic levels (most common in known epileptics)
			*Acute CNS injury: [[Stroke (main)\|stroke]], [[Traumatic brain injury\|TBI]], [[Meningitis\|CNS infection]], tumor
			*Metabolic: [[Hypoglycemia\|hypoglycemia]], [[Hyponatremia\|hyponatremia]], [[Hypocalcemia\|hypocalcemia]], hepatic failure, uremia
			*Toxicologic: [[Ethanol withdrawal\|alcohol withdrawal]], [[Benzodiazepine withdrawal]], [[Isoniazid toxicity\|INH]], [[Organophosphate toxicity\|organophosphates]], [[Cocaine toxicity\|cocaine]], [[Tricyclic antidepressant toxicity\|TCA]]
			*[[Eclampsia]] (pregnant/postpartum patients)
			*Febrile status epilepticus in children

	==Clinical Features==		==Clinical Features==
	*~~[[Seizure]] > 20 minutes. <ref>Brodie MJ. Status epilepticus in adults. Lancet. 1990 Sep 1; 336(8714)~~:~~551~~-~~2.</ref>~~		*Generalized convulsive SE: continuous tonic-clonic activity, most readily recognized
	*~~Presume~~ status in ~~current~~ seizure ~~> 5 minutes<ref>Lowenstein DH~~, ~~Alldredge BK. Status epilepticus. N Engl J Med. 1998; 338:970-976</ref>~~		*Non-convulsive SE: subtle or no motor manifestations; persistent altered mental status
			**Must maintain high suspicion in patients who remain altered after apparent seizure cessation
			*Complications: [[Rhabdomyolysis\|rhabdomyolysis]], [[Hyperthermia\|hyperthermia]], lactic acidosis, aspiration, neuronal injury

	==Differential Diagnosis==		==Differential Diagnosis==
Línea 14:		Línea 24:

	==Evaluation==		==Evaluation==
	*~~Clinical diagnosis~~		*'''Bedside glucose''' — immediately
	*~~Consider emergent~~ CT head~~, plus/minus~~ LP		*'''Labs''': BMP (Na, Ca, Mg, glucose), CBC, AED levels, lactate, VBG, LFTs, toxicology screen
	*~~Consider the following labs~~:		*'''CT head''' — once stabilized; evaluate for structural cause
	**~~VBG~~		*'''Continuous EEG''' — if available; essential to diagnose non-convulsive SE
	**Repeat glucose ~~checks~~		*LP if infection suspected (after CT and when safe)
	**~~Electrolytes including Na~~, Ca, Mg		*CK, urinalysis (myoglobinuria) if prolonged seizure
	**~~Tox screen~~
	**Serum beta HCG		==Management==
	**CK		===Time 0-5 min: Stabilize===
	**Lactate		*ABCs, supplemental O2, cardiac monitor, IV access
	**Anti-seizure medication levels		*'''Glucose''': check immediately; give '''D50W 50 mL IV''' (or D10W) if hypoglycemic
			*'''Thiamine 100 mg IV''' before glucose if malnourished or alcoholic
			*Position patient to prevent aspiration; suction as needed

			===Time 5-20 min: First-Line — Benzodiazepines===
			*'''[[Lorazepam]]''' 0.1 mg/kg IV (max 4 mg/dose), may repeat x1 in 5 min<ref name="silber">Silbergleit R, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. ''N Engl J Med''. 2012;366(7):591-600. PMID 22335736.</ref>
			*If no IV access: '''[[Midazolam]]''' 10 mg IM (most effective prehospital per RAMPART trial)
			*Alternatives: [[Diazepam]] 0.2 mg/kg IV (max 10 mg), or diazepam 20 mg PR

			===Time 20-40 min: Second-Line — Anti-Epileptic Drug===
			*'''[[Levetiracetam]]''' 60 mg/kg IV (max 4500 mg) over 15 min<ref name="kapur">Kapur J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus (ESETT). ''N Engl J Med''. 2019;381(22):2103-2113. PMID 31774955.</ref>
			*'''[[Fosphenytoin]]''' 20 mg PE/kg IV (max rate 150 mg PE/min)
			*'''[[Valproic acid]]''' 40 mg/kg IV (max 3000 mg) over 10 min
			*ESETT trial: all three equally effective (~50% success each)

	==~~Managment~~==		===Time >40 min: Refractory SE===
	~~{{Seizure actively seizing management}}~~		*'''[[Intubation (main)\|Intubation]]''' and continuous infusion of anesthetic agent:
			**'''[[Midazolam]]''' 0.2 mg/kg IV bolus, then 0.1-2 mg/kg/hr
			**'''[[Propofol]]''' 2 mg/kg IV bolus, then 2-10 mg/kg/hr (monitor for propofol infusion syndrome)
			**'''[[Pentobarbital]]''' 5 mg/kg IV bolus, then 1-5 mg/kg/hr
			*Continuous EEG monitoring required
			*Target: burst-suppression for 24-48 hours

			===Special Situations===
			*'''[[Isoniazid toxicity\|INH overdose]]''': '''Pyridoxine (B6)''' gram-for-gram (empiric 5 g IV if dose unknown)
			*'''[[Eclampsia]]''': '''Magnesium sulfate''' 4-6 g IV
			*'''[[Hyponatremia]]''': '''Hypertonic saline (3%)''' 100 mL IV bolus

	==Disposition==		==Disposition==
	*~~Admit to~~ ICU ~~or intermediate level of monitored care depending on etiology, treatments and respiratory status~~		*'''ICU admission''' for all SE patients
			*Neurology consultation
	~~==External Links==~~		*Patients with rapidly terminated seizures who return to baseline may be managed on a monitored floor
	*~~IBCC [https://emcrit.org/ibcc/status-epilepticus/ Status Epilepticus]~~ with ~~[https://emcrit.org/ibcc/status-epilepticus/#summary algorithm]~~
	*EM Nerd [https://emcrit.org/emnerd/adventure-dancing-men/ Adventure of dancing men]
	*[https://emcrit.org/pulmcrit/esett/ PulmCrit: ESETT Trial]

	==See Also==		==See Also==
	*[[Seizure]]		*[[Seizure]]
	*[[~~Prehospital protocol pediatric~~ seizure]]		*[[First-time seizure]]
	*[[~~Status Epilepticus (peds)~~]]		*[[Eclampsia]]
			*[[Febrile seizure]]
			*[[Ethanol withdrawal]]

	==References==		==References==

Ostermayer at 18:12, 16 January 2026

2026-01-16T18:12:08Z

← Revisión anterior		Revisión del 18:12 16 ene 2026
Línea 1:		Línea 1:
	{{~~Adult top}} [[~~Status epilepticus (peds)~~]].''~~		{{AdultPage\|Status epilepticus (peds)}}
	==Background==		==Background==
	*Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments or recurrent seizure activity without return to baseline mental status.<ref>Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9</ref><ref>Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8</ref> (Previous definitions used a 30-minute time limit)<ref>Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.</ref>		*Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments or recurrent seizure activity without return to baseline mental status.<ref>Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9</ref><ref>Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8</ref> (Previous definitions used a 30-minute time limit)<ref>Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.</ref>

Rossdonaldson1 at 19:23, 19 October 2022

2022-10-19T19:23:43Z

← Revisión anterior		Revisión del 19:23 19 oct 2022
Línea 1:		Línea 1:
	{{Adult top}} [[~~tatus~~ epilepticus (peds)]].''		{{Adult top}} [[Status epilepticus (peds)]].''
	==Background==		==Background==
	*Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments or recurrent seizure activity without return to baseline mental status.<ref>Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9</ref><ref>Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8</ref> (Previous definitions used a 30-minute time limit)<ref>Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.</ref>		*Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments or recurrent seizure activity without return to baseline mental status.<ref>Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9</ref><ref>Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8</ref> (Previous definitions used a 30-minute time limit)<ref>Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.</ref>

Rossdonaldson1 at 18:55, 19 October 2022

2022-10-19T18:55:05Z

← Revisión anterior		Revisión del 18:55 19 oct 2022
Línea 1:		Línea 1:
			{{Adult top}} [[tatus epilepticus (peds)]].''
	==Background==		==Background==
	*Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments or recurrent seizure activity without return to baseline mental status.<ref>Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9</ref><ref>Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8</ref> (Previous definitions used a 30-minute time limit)<ref>Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.</ref>		*Definitions have varied, but status epilepticus should be considered in a patient seizing for 5-10min despite initial treatments or recurrent seizure activity without return to baseline mental status.<ref>Epilepsy Foundation of America. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993 Aug 18. 270(7):854-9</ref><ref>Lowenstein DH, Cloyd J. Out-of-hospital treatment of status epilepticus and prolonged seizures. Epilepsia. 2007. 48 Suppl 8:96-8</ref> (Previous definitions used a 30-minute time limit)<ref>Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592.</ref>

SMReel: /* See Also */

2022-10-04T17:50:53Z

SMReel: /* See Also */

2022-10-04T17:50:07Z

Elcatracho: /* External Links */

2021-02-04T16:17:36Z

External Links

← Revisión anterior		Revisión del 16:17 4 feb 2021
Línea 34:		Línea 34:
	*IBCC [https://emcrit.org/ibcc/status-epilepticus/ Status Epilepticus] with [https://emcrit.org/ibcc/status-epilepticus/#summary algorithm]		*IBCC [https://emcrit.org/ibcc/status-epilepticus/ Status Epilepticus] with [https://emcrit.org/ibcc/status-epilepticus/#summary algorithm]
	*EM Nerd [https://emcrit.org/emnerd/adventure-dancing-men/ Adventure of dancing men]		*EM Nerd [https://emcrit.org/emnerd/adventure-dancing-men/ Adventure of dancing men]
			*[https://emcrit.org/pulmcrit/esett/ PulmCrit: ESETT Trial]

	==See Also==		==See Also==

Kxl328: /* Evaluation */

2020-02-15T08:40:51Z

Evaluation

← Revisión anterior		Revisión del 08:40 15 feb 2020
Línea 14:		Línea 14:
	==Evaluation==		==Evaluation==
	*Clinical diagnosis		*Clinical diagnosis
			*Consider emergent CT head, plus/minus LP
	*Consider the following labs:		*Consider the following labs:
	**VBG		**VBG

Kxl328: /* Evaluation */

2020-02-15T08:40:19Z

Evaluation

← Revisión anterior		Revisión del 08:40 15 feb 2020
Línea 14:		Línea 14:
	==Evaluation==		==Evaluation==
	*Clinical diagnosis		*Clinical diagnosis
			*Consider the following labs:
			**VBG
			**Repeat glucose checks
			**Electrolytes including Na, Ca, Mg
			**Tox screen
			**Serum beta HCG
			**CK
			**Lactate
			**Anti-seizure medication levels

	==Managment==		==Managment==

← Revisión anterior		Revisión del 17:50 4 oct 2022
Línea 39:		Línea 39:
	*[[Seizure]]		*[[Seizure]]
	*[[Prehospital protocol pediatric seizure]]		*[[Prehospital protocol pediatric seizure]]
	*[[Status ~~epilepticus~~ (peds)]]		*[[Status Epilepticus (peds)]]

	==References==		==References==

← Revisión anterior		Revisión del 17:50 4 oct 2022
Línea 39:		Línea 39:
	*[[Seizure]]		*[[Seizure]]
	*[[Prehospital protocol pediatric seizure]]		*[[Prehospital protocol pediatric seizure]]
			*[[Status epilepticus (peds)]]

	==References==		==References==

← Revisión anterior		Revisión del 09:23 22 mar 2026
Línea 25:		Línea 25:
	==Evaluation==		==Evaluation==
	*'''Bedside glucose''' — immediately		*'''Bedside glucose''' — immediately
	*~~'''~~Labs~~'''~~: BMP (Na, Ca, Mg, glucose), CBC, AED levels, lactate, VBG, LFTs, toxicology screen		*Labs: BMP (Na, Ca, Mg, glucose), CBC, AED levels, lactate, VBG, LFTs, toxicology screen
	*~~'''~~CT head~~'''~~ — once stabilized; evaluate for structural cause		*CT head — once stabilized; evaluate for structural cause
	*~~'''~~Continuous EEG~~'''~~ — if available; essential to diagnose non-convulsive SE		*Continuous EEG — if available; essential to diagnose non-convulsive SE
	*LP if infection suspected (after CT and when safe)		*LP if infection suspected (after CT and when safe)
	*CK, urinalysis (myoglobinuria) if prolonged seizure		*CK, urinalysis (myoglobinuria) if prolonged seizure
Línea 35:		Línea 35:
	*ABCs, supplemental O2, cardiac monitor, IV access		*ABCs, supplemental O2, cardiac monitor, IV access
	*'''Glucose''': check immediately; give '''D50W 50 mL IV''' (or D10W) if hypoglycemic		*'''Glucose''': check immediately; give '''D50W 50 mL IV''' (or D10W) if hypoglycemic
	*~~'''~~Thiamine 100 mg IV~~'''~~ before glucose if malnourished or alcoholic		*Thiamine 100 mg IV before glucose if malnourished or alcoholic
	*Position patient to prevent aspiration; suction as needed		*Position patient to prevent aspiration; suction as needed

	===Time 5-20 min: First-Line — Benzodiazepines===		===Time 5-20 min: First-Line — Benzodiazepines===
	*'''[[Lorazepam]]''' 0.1 mg/kg IV (max 4 mg/dose), may repeat x1 in 5 min<ref name="silber">Silbergleit R, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. ''N Engl J Med''. 2012;366(7):591-600. PMID 22335736.</ref>		*'''[[Lorazepam]]''' 0.1 mg/kg IV (max 4 mg/dose), may repeat x1 in 5 min<ref name="silber">Silbergleit R, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. ''N Engl J Med''. 2012;366(7):591-600. PMID 22335736.</ref>
	*If no IV access: ~~'''~~[[Midazolam]]~~'''~~ 10 mg IM (most effective prehospital per RAMPART trial)		*If no IV access: [[Midazolam]] 10 mg IM (most effective prehospital per RAMPART trial)
	*Alternatives: [[Diazepam]] 0.2 mg/kg IV (max 10 mg), or diazepam 20 mg PR		*Alternatives: [[Diazepam]] 0.2 mg/kg IV (max 10 mg), or diazepam 20 mg PR

	===Time 20-40 min: Second-Line — Anti-Epileptic Drug===		===Time 20-40 min: Second-Line — Anti-Epileptic Drug===
	*'''[[Levetiracetam]]''' 60 mg/kg IV (max 4500 mg) over 15 min<ref name="kapur">Kapur J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus (ESETT). ''N Engl J Med''. 2019;381(22):2103-2113. PMID 31774955.</ref>		*'''[[Levetiracetam]]''' 60 mg/kg IV (max 4500 mg) over 15 min<ref name="kapur">Kapur J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus (ESETT). ''N Engl J Med''. 2019;381(22):2103-2113. PMID 31774955.</ref>
	*~~'''~~[[Fosphenytoin]]~~'''~~ 20 mg PE/kg IV (max rate 150 mg PE/min)		*[[Fosphenytoin]] 20 mg PE/kg IV (max rate 150 mg PE/min)
	*~~'''~~[[Valproic acid]]~~'''~~ 40 mg/kg IV (max 3000 mg) over 10 min		*[[Valproic acid]] 40 mg/kg IV (max 3000 mg) over 10 min
	*ESETT trial: all three equally effective (~50% success each)		*ESETT trial: all three equally effective (~50% success each)

	===Time >40 min: Refractory SE===		===Time >40 min: Refractory SE===
	*'''[[Intubation (main)\|Intubation]]''' and continuous infusion of anesthetic agent:		*'''[[Intubation (main)\|Intubation]]''' and continuous infusion of anesthetic agent:
	**~~'''~~[[Midazolam]]~~'''~~ 0.2 mg/kg IV bolus, then 0.1-2 mg/kg/hr		**[[Midazolam]] 0.2 mg/kg IV bolus, then 0.1-2 mg/kg/hr
	**~~'''~~[[Propofol]]~~'''~~ 2 mg/kg IV bolus, then 2-10 mg/kg/hr (monitor for propofol infusion syndrome)		**[[Propofol]] 2 mg/kg IV bolus, then 2-10 mg/kg/hr (monitor for propofol infusion syndrome)
	**~~'''~~[[Pentobarbital]]~~'''~~ 5 mg/kg IV bolus, then 1-5 mg/kg/hr		**[[Pentobarbital]] 5 mg/kg IV bolus, then 1-5 mg/kg/hr
	*Continuous EEG monitoring required		*Continuous EEG monitoring required
	*Target: burst-suppression for 24-48 hours		*Target: burst-suppression for 24-48 hours

	===Special Situations===		===Special Situations===
	*~~'''~~[[Isoniazid toxicity\|INH overdose]]~~'''~~: ~~'''~~Pyridoxine (B6)~~'''~~ gram-for-gram (empiric 5 g IV if dose unknown)		*[[Isoniazid toxicity\|INH overdose]]: Pyridoxine (B6) gram-for-gram (empiric 5 g IV if dose unknown)
	*~~'''~~[[Eclampsia]]~~'''~~: ~~'''~~Magnesium sulfate~~'''~~ 4-6 g IV		*[[Eclampsia]]: Magnesium sulfate 4-6 g IV
	*~~'''~~[[Hyponatremia]]~~'''~~: ~~'''~~Hypertonic saline (3%)~~'''~~ 100 mL IV bolus		*[[Hyponatremia]]: Hypertonic saline (3%) 100 mL IV bolus

	==Disposition==		==Disposition==
	*~~'''~~ICU admission~~'''~~ for all SE patients		*ICU admission for all SE patients
	*Neurology consultation		*Neurology consultation
	*Patients with rapidly terminated seizures who return to baseline may be managed on a monitored floor		*Patients with rapidly terminated seizures who return to baseline may be managed on a monitored floor