Your patient arrives by ambulance having a seizure.  EMS administered ativan 10 minutes ago.  You give a second dose but the seizure continues.  What should you do?

Status Epilepticus (SE)

Seizures that are prolonged or recur before the patient fully recovers.

The exact meaning of prolonged is evolving.  Most seizures are brief, resolving spontaneously in less than 1-2 minutes.  It is known from animal studies that within minutes of a non-resolving seizure there are synaptic changes that quickly lead to neuropeptide expresion changes and ultimately excitotoxicity that “culminates in neuronal death.” [2]  Prolonged seizure duration results in treatment resistance, especially to benzodiazepines.  [1]    Based on this and proven benefit to early treatment, it is now defined that convulsive SE must be treated within 5 minutes, [1,3]  and any patient who arrives having a seizure should be considered to have SE.

Beware of of patients who remain unresponsive after initial treatment, as nonconvulsive SE is seen in nearly 50% of comatose patients after control of convulsive SE.  [1]  In one study, mean unresponsive time after generalized convulsion (by video monitoring) is 4 minutes and max 20 minutes before non-respiratory movement. [4]  If your patient is not moving within 20 minutes of cessation of convulsion suspect status!

This short time frame has led to a focus on initiating treatment in the prehospital setting.  algorythmic prehospital and emergency care is effective in reducing the duration of SE.

  • Treatment: (protocol from [2])
    • Within 5 minutes: Lorazepam 4mg IV, repeat x 1 in 5 minutes
      Alt: midazolam 10mg IM, diazepam 20mg PR

      • under/late dosing decrease treatment efficacy
      • remeber ABC, IV, monitoring
      • labs: cbc, bmp, Ca, Mg, Po4, LFT, trop, AED levels, blood gas
      • glucose level, treat with thiamine then glucose
    • within 30 minutes: Fosphenytoin then midazolam (can also complete simultaneously)
      -Fosphenytoin 20mg/kg up to 150mg/min
      -Midazolam: 0.2mg/kg q 5 minutes (max 2mg/kg), start drip 0.2mg/kg/h
      Alt: valproate, levetiracetam, lacosamide

      • Some protocols beginning to favor directly moving to anesthetics skipping this phase… time is brain
    • >30 minutes: ICU, treatment with continuous EEG, neurologist
      pentobarbital 5mg/kg q 5 then drip or propofol 1-2mg/kg q5 min then drip

Fosphenytoin is the prodrug of phenytoin.  It is more expensive.  Less hypotension.  faster infusion.  both drugs cause arrythmia and respiratory depression.  both have many drug-drug interactions.  [2]




1)Betjemann, John P., and Daniel H. Lowenstein. “Status Epilepticus in Adults.” The Lancet Neurology 14.6 (2015): 615-24. Web.
2)Arbo, John E., Stephen Ruoss, Geoffrey K. Lighthall, Michael P. Jones, and Joshua Stillman. Decision Making in Emergency Critical Care: An Evidence-based Handbook. N.p.: n.p., n.d. Print.
3)Lowenstein, Daniel H., Thomas Bleck, and Robert L. Macdonald. “It’s Time to Revise the Definition of Status Epilepticus.” Epilepsia 40.1 (1999): 120-22. Web.
4) Seyal, Masud, Lisa M. Bateman, and Chin-Shang Li. “Impact of Periictal Interventions on Respiratory Dysfunction, Postictal EEG Suppression, and Postictal Immobility.” Epilepsia 54.2 (2012): 377-82. Web.