Convulsive Status Epilepticus

Status epilepticus is seizure activity lasting >5 minutes, or recurrent seizures without recovery of consciousness between episodes. Mortality rises significantly after 30 minutes. Treatment follows a strict time-based ladder.

Status Epilepticus Time-Based Protocol

The pathway

1 · First 5 minutes

Safe positioning, recovery position if possible
Time the seizure from onset
O₂ 15L NRB
IV/IO access
BM immediately

2 · Benzodiazepine — first dose

IV lorazepam 4mg over 2 minutes
If no IV: buccal midazolam 10mg or IM midazolam 10mg

3 · Benzodiazepine — second dose

Repeat lorazepam 4mg IV if still seizing 5–10 minutes after the first dose
Alert senior now

4 · Second-line — after two benzodiazepines

Only once two benzodiazepine doses have failed
Levetiracetam 60mg/kg IV (max 4500mg) over 10 min — usually quickest, fewest adverse effects
OR sodium valproate 40mg/kg IV over 10 min
OR phenytoin 20mg/kg IV (max 2g) at ≤50mg/min (25mg/min if elderly or cardiac). Continuous ECG and BP; dilute in 0.9% NaCl, never glucose
Call ITU

5 · Third-line — if second-line fails

Phenobarbital or general anaesthesia, under expert guidance
RSI, ITU, propofol or thiopental infusion
EEG monitoring

6 · Post-ictal

BM, neuro obs, recovery position
Investigate cause: Na, K, Ca, Mg, glucose, FBC, LFTs, CXR, ECG, CT head (if first seizure or new features)

Drugs

Drug	Dose	Route	Notes
Lorazepam	4mg	IV	First-line with IV access. Repeat once if still seizing 5–10 minutes after the first dose.
Midazolam	10mg	Buccal/IM	First-line without IV access.
Levetiracetam	60mg/kg (max 4500mg)	IV	Usually the first choice of the three second-line options — quickest to give, fewest adverse effects. Over 10 minutes.
Sodium valproate	40mg/kg	IV	Avoid in liver disease, pregnancy. Over 10 minutes.
Phenytoin	20mg/kg (max 2g)	IV	Rate ≤50mg/min — 25mg/min if elderly or cardiac disease. Continuous ECG and BP. Dilute in 0.9% NaCl; precipitates in glucose.
Dextrose 10%	150ml	IV	If BM <4 mmol/L. Recheck BM at 10 minutes, then 30-minutely until stable.

When to escalate

Still seizing after two benzodiazepine doses — call ITU and start second-line,Still seizing after a second-line drug — anaesthetics for RSI, EEG monitoring,Airway compromise,BM <4 (hypoglycaemia),Na <125 (hyponatraemia as cause)

Reference: NICE NG217 Epilepsies (2022, updated 2025; replaced CG137) / APLS

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