Status Epilepticus: The Most Life-Threatening Seizure Emergency

Definition

Status epilepticus (SE) is a neurologic emergency defined as:

• A single seizure lasting >5 minutes, OR
• Two or more seizures without full recovery of consciousness between them.

Mortality and Urgency

• Mortality: 10–20% overall; up to 40% in refractory SE; higher in elderly and those with CNS infections.
• Time is brain: Neuronal injury begins after ~30 minutes of continuous convulsive SE; systemic complications (rhabdomyolysis, hyperthermia, aspiration, cardiac arrhythmias) escalate rapidly.

Types

• Convulsive SE: Generalized tonic-clonic (most recognized).
• Non-convulsive SE: Absence status, complex partial status – subtle, diagnosed by EEG.

Immediate Management (Algorithm)

1. 0–5 min: Secure airway, O₂, IV access, glucose check, benzodiazepine (IV lorazepam 4 mg or IM midazolam 10 mg).
2. 5–20 min: Second-line ASM: fosphenytoin/phenytoin, valproate, or levetiracetam.
3. 20–40 min: Third-line: continuous IV anesthetic (midazolam, propofol, pentobarbital) with EEG monitoring in ICU.
4. Identify/treat cause: AED non-adherence, stroke, tumor, infection, metabolic derangement, drug toxicity.

Key Message

Any seizure lasting >5 minutes requires emergency medical activation. Bystanders should call 911 immediately—do not wait for spontaneous cessation.