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status epilepticus

diagnosis of convulsive status epilepticus

either of following:

  • ≥ minutes of continuous seizure activity
  • ≥ 2 discrete seizures with incomplete recovery of consciousness in between

diagnosis of non-convulsive status epilepticus (NCSE) (from Beniczky et al.)

  • epileptic discharges (EDs) qualified as following:
    • spikes, poly spikes, sharp-waves, sharp-and-slow-wave complexes

without known epileptic encephalopathy

one of the following:

  • EDs > 2.5 Hz
  • EDs < 2.5 OR rhythmic delta/theta activity (>0.5 Hz) AND one of the following:
    • improvement in EEG & clinical status after IV anti-seizure drug (ASD)
      • consider as possible NCSE if: EEG improvement w/o clinical improvement OR fluctuation w/o definite evolution
    • subtle clinical ictal phenomena during aforementioned EEG patterns
    • typical spatiotemporal evolution, e.g.:
      • incrementing onset (increase in voltage & change in frequency)
      • evolution in pattern (change in frequency > 1 Hz or change in location)
      • decrementing termination (voltage or frequency)

with known encephalopathy

  • increase in prominence or frequency of above features vs. baseline with observable change in clinical state
  • improvement of clinical & EEG features with IV ASD



  • assess airway, breathing circulation
  • oxygen
  • cardiac monitoring w telemetry
  • fingerstick glucose
    • if fingerstick < 60 mg/dl then:
      • adults 100mg thiamine IV then 50mL D50W IV
      • children ≥ 2 years: 2 ml/kg D25W IV & children < 2 years: 4 ml/kg 12.5W
  • basic labs (electrolytes, CBC, tox screen, if relevant ASD levels)

ASD step 1 = 1st line fast-onset/short-acting = benzos

  • can use ativan IV, diazepam IV, or midazolam IM

  • lorazepam = ativan IV

    • adult: 0.1mg/kg
    • peds: 0.05-0.5mg/kg
    • rate: 2mg/min
    • max recommended for adult & peds = 4mg. may repeat in ~5-10min (some sources state only repeat once, eg. Glauser et al.)
  • midazolam IM

    • 13-40kg: 5mg
    • >40kg: 10mg
    • (some sources state use single dose, e.g. Glauser et al.)
  • diazepam IV

    • 0.15-0.2mg/kg/dose
    • max 10mg/dose
    • can repeat once
  • if not of above available:

    • IV phenobarbital 15 mg/kg/dose
    • rectal diazepam 0.2-0.5mg/kg, max 20mg/dose
    • midazolam: intranasal, buccal

ASD step 2 = 1st line longer-acting anti-seizure drug (semantics/convention: sometimes called 2nd line)

  • fosphenytoin or phenytoin IV

    • adults & peds: 20mg/kg (some state 18-20mg/kg)
    • max 1500mgPE/dose
    • rate: fosphenytoin 150mg/min or phenytoin 50mg/min
    • effective ~10-30min after admin
  • valproate as alternative

    • load: 20-25mg/kg IV
    • max 3000mg/dose
    • rate: adults: 3-6mg/kg/min & peds 1.5-3mg/kg/min
  • levetiracetam (keppra)

    • load ~1.5g (~1-3g per uptodate) at 2-5 mg/kg/mins
      • others, e.g. Glauser et al., cite 60mg/kg with max 4500mg/dose
  • if above not available:

    • IV phenobarbital 15mg/kg

*note: levetiracetam (keppra) & lacosamide not recommended as 1st/2nd line agents for status * however keppra is nonetheless widely used given relatively favorable side effect profile

ASD step 3 if warranted - repeat another dose of the same longer-acting ASD

  • may bolus ~1/3 prior dose (i.e. phenytoin or valproate)

    • can give ~5-10mg/kg
  • note: while not in formal algorithms, in practice another agent might be considered (i.e. if initially gave keppra, might then try phenytoin if hemodynamically stable)

ASD step 4 if warranted - sedatives/anesthetics

  • consider intubation / ICU and infusion of anesthetic agent:

    • midazolam
    • propofol
    • pentobarbital
    • thiopental
  • treat to burst suppression for 12-48 hrs

  • then gradually withdraw w continuous EEG monitoring

references include

  • 2013 Beniczky et al. article in Epilepsia ("Unified EEG terminology and criteria for nonconvulsive status epilepticus")
  • including "Convulsive status epilepticus in adults: Classification, clinical features, and diagnosis"
  • Mayo Clinic Neurology Board Review book ISBN-13 978-0190244897
  • Neurology Continuum
  • Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Glauser et al. 2017