Status Epilepticus
>5 min
Definition
Continuous seizure or 2+ without baseline return
0.1 mg/kg
Lorazepam Dose
First-line IV benzodiazepine
3
Treatment Tiers
Benzo then AED then continuous infusion
Recognition and First Actions
airway, benzo, glucose, in that orderContinuous seizure activity lasting 5 minutes or longer
Two or more seizures without return to neurologic baseline
Protect the airway and position patient safely
Lorazepam 0.1 mg/kg IV (max 4 mg per dose, may repeat once)
Midazolam 10 mg IM if no IV access
Check bedside glucose immediately
Obtain IV access if not already established
First action after recognizing status is protect airway and give benzodiazepine. Check glucose.
Second-Line and Refractory Management
Levetiracetam, fosphenytoin, or valproate as second-line
Fosphenytoin requires cardiac monitoring during infusion
Refractory status = continuous infusion (propofol, midazolam, or pentobarbital)
Continuous EEG monitoring mandatory for refractory status
Intubation often required for airway protection in refractory cases
Key Values to Memorize
Status = 5 min continuous
Lorazepam 0.1 mg/kg IV
Midazolam 10 mg IM
Max lorazepam 4 mg/dose
Refractory = cEEG required
Always check glucose
status epilepticus management is a must-know for the CCRN
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Practice CCRN QuestionsExam Traps
5 minutes not 30
The old definition of status epilepticus was 30 minutes. Current guidelines define it as 5 minutes of continuous seizure activity or 2 or more seizures without return to baseline. The exam uses the current 5-minute definition.
Lorazepam IV or midazolam IM first
Benzodiazepines are always first-line for status epilepticus. Lorazepam IV is preferred in the hospital. Midazolam IM is preferred when IV access is not available. Do not skip to second-line agents.
Refractory means continuous infusion plus EEG
If seizures persist after benzodiazepine and a second-line AED, the patient has refractory status. Treatment is continuous infusion of propofol, midazolam, or pentobarbital with continuous EEG monitoring to confirm seizure suppression.
Always check glucose
Hypoglycemia can cause seizures and mimic status epilepticus. A bedside glucose check takes seconds and may reveal a rapidly reversible cause. The exam tests whether you check glucose early.
The 5-Minute Rule
5 minutes of continuous seizing = status epilepticus. The old 30-minute definition is outdated. Treat at 5 minutes.
Tiered Approach
Tier 1 = benzo. Tier 2 = AED (levetiracetam, fosphenytoin). Tier 3 = continuous infusion + EEG. Do not skip tiers.
The brain is having an electrical storm. Neurons are firing uncontrollably in a feedback loop. The longer the storm rages, the harder it is to stop and the more damage it causes to brain tissue.
Benzodiazepines are the circuit breaker. They enhance GABA, the brain's main inhibitory neurotransmitter, slamming the brakes on that runaway electrical activity. This is why they are always first.
Second-line AEDs like levetiracetam and fosphenytoin are the surge protector. They stabilize the electrical system to prevent the storm from restarting after the circuit breaker trips.
If the storm keeps going, you shut down the entire power grid with continuous infusion and watch the EEG to make sure it stays quiet. This is refractory status and requires ICU-level monitoring.
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