Status epilepticus
Protect the airway, check the sugar, give a benzodiazepine at 5 minutes and once more if needed, then a second-line drug by 20 minutes and anaesthesia by 40.
A 32-year-old man with epilepsy is brought in fitting. His brother says he ran out of his tablets three days ago and the fit started 10 minutes ago at home. He is jerking all four limbs, his lips are blue and he is not responding.
What do you do, and by when?
- Time it, call for helpNote the time the fit started. Status = 5 minutes or more of fitting, or fits without recovery in between.
- Airway and oxygenRecovery position, suction, high-flow oxygen. Do not put anything in the mouth.
- Check the sugar nowBelow 70 mg/dL (3.9 mmol/L): give IV dextrose.
- First benzodiazepine at 5 minutesIV lorazepam or diazepam. Buccal or IM midazolam if no IV access.
- Second dose at 10 minutesOnly one repeat. Count all doses, including any given at home or in the ambulance.
- Second-line drug by 20 minutesLevetiracetam, phenytoin or valproate.
- Still fitting at 30–40 minutesICU and anaesthetist: general anaesthesia and intubation.
- Find the causeSugar, sodium, calcium, eclampsia, infection, alcohol, poisoning, missed tablets.
- Fitting for 5 minutes, or repeated fits without recovery
- A second benzodiazepine is needed
- Pregnant or recently delivered
- Fever, neck stiffness or rash
- Head injury or on blood thinners
- Not waking up after the fit stops
- Low blood sugar
- Eclampsia
- Meningitis, encephalitis or cerebral malaria
- Low sodium
- Brain bleed or tumour
- Alcohol withdrawal
- Organophosphate or isoniazid poisoning
| Status epilepticus | Fitting 5 minutes or more, or repeated fits without recovery |
| Benzodiazepines | Two doses at most, including pre-hospital doses |
| Low sugar | Below 70 mg/dL (3.9 mmol/L): 10% dextrose 150–200 mL IV, or 50 mL of 50% |
| Alcohol or malnourished | Thiamine before or with the dextrose |
| Pregnant or just delivered | Think eclampsia: magnesium sulfate |
Check every dose against a current drug reference and your hospital protocol.
On this page
What status epilepticus is
Most fits stop by themselves within 2–3 minutes. A fit that lasts 5 minutes or more, or fits that follow each other without the patient waking in between, are unlikely to stop on their own. This is status epilepticus. The longer it goes on, the harder it is to stop and the more damage it does to the brain, so treatment follows the clock.
The timeline
- 0 minFit starts: airway, oxygen, sugar
- 5 minFirst benzodiazepine
- 10 minSecond benzodiazepine (only one repeat)
- 20 minSecond-line drug
- 30–40 minICU: anaesthesia
First steps
- AirwayRecovery position, suction the mouth. Jaw thrust if needed. Never force anything between the teeth.
- Oxygen15 L/min by non-rebreather mask.
- SugarBedside glucose now.
- IV accessBloods: sugar, sodium, calcium, magnesium, urea, creatinine, LFTs, CBC, drug levels if on phenytoin or valproate, pregnancy test in women, blood gas.
- Protect from injuryMove furniture, pad the bed rails. Do not hold the limbs down.
- Collateral historyEpilepsy? Missed tablets? Alcohol? Pregnancy? Head injury? Fever? Poisoning? Drugs already given?
First-line: benzodiazepines
Two doses of benzodiazepine at most, counting any given at home or in the ambulance. More doses do not stop the fit and cause breathing to stop. Move on to the second-line drug.
Low sugar, alcohol and pregnancy
Second-line drugs
Start the second-line drug once two doses of benzodiazepine have failed, ideally by 20 minutes. In the ESETT trial, levetiracetam, fosphenytoin and valproate were similarly effective, so choose by availability and the patient.
- 60 mg/kg IV over 10 minutes, maximum 4.5 g
- Few interactions, safe in pregnancy and liver disease
- Reduce dose in kidney failure
- 20 mg/kg IV, no faster than 50 mg/minute
- Continuous ECG and BP: can cause arrhythmia and low BP
- Mix only in 0.9% sodium chloride
- Avoid if already on phenytoin with a good level
- 40 mg/kg IV over 10 minutes, maximum 3 g
- Avoid in women who could become pregnant, liver disease, and children under 2
Third-line: refractory status
If the patient is still fitting 30–40 minutes after the start, or 10 minutes after the second-line drug: this is refractory status epilepticus.
- ICU and the anaesthetist now.
- General anaesthesia (for example propofol or midazolam infusion) with intubation and ventilation.
- EEG monitoring where available, because fits can continue without visible jerking.
Finding the cause
| Cause | Clues | Action |
|---|---|---|
| Missed or stopped epilepsy tablets | Known epilepsy, ran out of tablets | Restart usual drug once stable |
| Low sugar | Diabetic on insulin or sulfonylurea | Dextrose |
| Eclampsia | Pregnant over 20 weeks or recently delivered, high BP, protein in urine | Magnesium, obstetric team |
| Meningitis or encephalitis | Fever, neck stiffness, rash, confusion | Ceftriaxone and aciclovir, see Meningitis |
| Cerebral malaria | Fever, endemic area, low sugar | Malaria test, IV artesunate |
| Low sodium or calcium | Vomiting, diuretics, recent surgery | Electrolytes, senior advice |
| Head injury or brain bleed | Trauma, blood thinners, focal signs | CT head |
| Tuberculous meningitis or neurocysticercosis | Weeks of headache and fever, or ring lesions on CT | CT or MRI, specialist |
| Alcohol withdrawal | Heavy drinking, stopped 1–3 days ago | Benzodiazepines, thiamine |
| Isoniazid poisoning | On TB treatment, overdose | Pyridoxine IV, senior advice |
| Organophosphate poisoning | Smell, small pupils, secretions | Atropine, see Organophosphate poisoning |
After the fit stops
- Recovery position, oxygen, regular observations and GCS.
- The patient may be drowsy for hours. If they are not improving, or the GCS stays low, get a CT head and consider non-convulsive status (EEG).
- Restart regular epilepsy medicines. Check the dose and that they can obtain them.
- CT head if this is a first fit, a head injury, focal signs, on blood thinners, or not recovering as expected.
- Advise: no driving until reviewed. Avoid swimming or bathing alone.
Common mistakes
- Forgetting the sugar.
- Giving a third and fourth dose of diazepam instead of moving to the second-line drug.
- Running phenytoin fast, or mixing it with dextrose.
- Giving valproate to a young woman without considering pregnancy.
- Missing eclampsia in a woman who delivered last week.
- Assuming the patient is "post-ictal" for hours without looking for ongoing fits or a cause.
Frequently asked questions
When is a seizure called status epilepticus?
When a fit lasts 5 minutes or more, or when fits follow each other without recovery in between.
What is the first-line treatment for status epilepticus?
A benzodiazepine: lorazepam 4 mg IV or diazepam 10 mg IV, repeated once after 5–10 minutes if still fitting. Buccal or IM midazolam 10 mg if there is no IV access.
What is the loading dose of levetiracetam in status epilepticus?
60 mg/kg IV over 10 minutes, to a maximum of 4.5 g.
What is the loading dose of phenytoin?
20 mg/kg IV, given no faster than 50 mg per minute, in 0.9% sodium chloride, with ECG and BP monitoring.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A 30-year-old man had rectal diazepam at home and IV diazepam in the emergency department. He is still fitting 10 minutes later. What is the next step?
Answer: IV levetiracetam. After two doses of benzodiazepine, give a second-line IV drug: levetiracetam, phenytoin or valproate. If still fitting, anaesthesia and intubation.
- A third benzodiazepine dose: More than two benzodiazepine doses adds respiratory depression without benefit.
- Wait 10 more minutes: Prolonged seizures cause brain injury.
- IV haloperidol: Not an antiepileptic.
- Oral carbamazepine: Too slow, and the route is unsafe.
2. A woman is fitting 5 days after delivery. BP is 168/110. Which drug must be given?
Answer: Magnesium sulfate. Eclampsia can occur up to several weeks after delivery. Magnesium sulfate: 4 g IV over 5–10 minutes, then 1 g/hour, with BP control.
- Levetiracetam: Not first-line for eclampsia.
- Labetalol alone: BP control is needed but doesn't stop eclamptic fits.
- Phenytoin: Magnesium is superior for eclamptic fits.
- Diazepam infusion: Magnesium is the treatment for eclampsia.
3. A 45-year-old man with heavy alcohol use is fitting. Capillary glucose is 2.9 mmol/L (52 mg/dL). What should be given?
Answer: IV dextrose and IV thiamine, without delaying the dextrose. Hypoglycaemia must be corrected immediately. Give thiamine as well in anyone with alcohol use or malnutrition, but don't delay dextrose for it.
- Oral glucose gel: Unsafe in a fitting patient.
- IV thiamine and wait 30 minutes before dextrose: Never delay treating hypoglycaemia.
- IM glucagon only: May fail in alcohol users with low glycogen stores.
- Lorazepam only: Treat the cause: the low sugar.
4. A 20-month-old had a 3-minute generalised seizure with fever from otitis media, and is now fully recovered and playing. Parents ask about the future. What is correct?
Answer: Low epilepsy risk; no prophylaxis. Simple febrile seizure: 6 months–5 years, generalised, < 15 minutes, single in 24 hours, full recovery. Recurrence ~30%; epilepsy risk only slightly higher than baseline (~1–2%). No investigations needed beyond finding the fever source; no prophylactic antiepileptics; antipyretics improve comfort but don’t prevent seizures. Teach first aid; buccal midazolam if prolonged. Complex seizures (focal, > 15 min, recurrent within 24 h) need further assessment; exclude meningitis.
- Start daily valproate: Prophylactic anticonvulsants are not indicated.
- Needs EEG and MRI urgently: A simple febrile seizure does not need EEG or MRI.
- Paracetamol prevents recurrence: Antipyretics do not prevent recurrence.
5. A term neonate born after prolonged labour with low Apgars has seizures at 12 hours. Glucose and calcium are normal. What is first-line anticonvulsant?
Answer: Phenobarbital. Neonatal seizures: commonest cause is hypoxic-ischaemic encephalopathy (first 24 h); also hypoglycaemia, hypocalcaemia, hypomagnesaemia, sepsis/meningitis, intracranial haemorrhage, inborn errors, drug withdrawal. Check glucose, calcium, magnesium, sodium, infection screen. First-line: phenobarbital (WHO 20 mg/kg IV); then phenytoin, levetiracetam, midazolam. Treat cause; therapeutic hypothermia for moderate–severe HIE where available.
- Phenytoin first-line: Phenytoin is second-line.
- Diazepam infusion: Diazepam infusion is not preferred in neonates.
- Carbamazepine: Carbamazepine is not used acutely.
6. Benzodiazepines, barbiturates and some anticonvulsants work by enhancing which neurotransmitter?
Answer: GABA. GABA is the main inhibitory neurotransmitter of the brain. Benzodiazepines increase the frequency of GABA-A chloride channel opening; barbiturates increase its duration. More chloride enters neurons, which become harder to excite. Flumazenil reverses benzodiazepines.
- Glutamate: The main excitatory transmitter; blocked by drugs like ketamine and memantine.
- Dopamine: Affected by antipsychotics and Parkinson's drugs.
- Acetylcholine: Affected by anticholinesterases and antimuscarinics.
- Serotonin: Affected by SSRIs and triptans.
7. A woman with epilepsy gives birth to a baby with a cleft palate and other birth defects. She took a drug for epilepsy throughout pregnancy. Which drug carries the highest overall teratogenic risk?
Answer: Sodium valproate. Sodium valproate has the highest risk of major malformations (about 10%), including neural tube defects, cleft palate and heart defects, and causes developmental delay. Phenytoin and carbamazepine also cause defects (fetal hydantoin syndrome, neural tube defects). Lamotrigine and levetiracetam are the safest choices.
- Lamotrigine: One of the safest antiepileptics in pregnancy.
- Levetiracetam: One of the safest antiepileptics in pregnancy.
- Carbamazepine: Teratogenic (neural tube defects) but lower risk than valproate.
- Phenobarbital: Teratogenic, but lower risk than valproate.
References and dose sources
- NICE NG217: Epilepsies in children, young people and adults
- Epilepsy Society
- ESETT trial: levetiracetam, fosphenytoin or valproate in status epilepticus
- NICE NG240
- Resus Council UK — resources
- Lorazepam dosing: Drugs.com: Lorazepam dosage (see also our lorazepam dose page)
- Diazepam dosing: Drugs.com: Diazepam dosage (see also our diazepam dose page)
- Midazolam dosing: Drugs.com: Midazolam dosage (see also our midazolam dose page)
- Dextrose (glucose) dosing: Drugs.com: Dextrose dosage (see also our dextrose (glucose) dose page)
- Thiamine (vitamin B1) dosing: Drugs.com: Thiamine dosage (see also our thiamine (vitamin b1) dose page)
- Magnesium sulfate dosing: Drugs.com: Magnesium sulfate dosage (see also our magnesium sulfate dose page)
- Levetiracetam dosing: Drugs.com: Levetiracetam dosage (see also our levetiracetam dose page)
- Phenytoin dosing: Drugs.com: Phenytoin dosage (see also our phenytoin dose page)
- Sodium valproate dosing: Drugs.com: Valproic acid dosage (see also our sodium valproate dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.