What is the algorithm for the emergency management of status epilepticus?

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Last updated: February 6, 2026 • View editorial policy

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Status Epilepticus Emergency Management Algorithm

Administer IV lorazepam 4 mg at 2 mg/min immediately as first-line treatment, followed by a second-line agent (valproate 20-30 mg/kg IV, levetiracetam 30 mg/kg IV, or fosphenytoin 20 mg PE/kg IV) if seizures continue beyond 5 minutes, and escalate to continuous midazolam infusion for refractory cases lasting beyond 20 minutes. 1

Stage 1: Immediate Stabilization (0-5 minutes)

Critical First Actions

  • Secure airway, provide high-flow oxygen, and establish IV access while simultaneously checking fingerstick glucose 1, 2
  • Correct hypoglycemia immediately if present—this is a rapidly reversible cause 1
  • Begin continuous vital sign monitoring, particularly respiratory status and blood pressure 1

First-Line Benzodiazepine Treatment

  • Administer IV lorazepam 4 mg at 2 mg/min (0.1 mg/kg, maximum 4 mg) 1, 3
  • Lorazepam demonstrates 65% efficacy in terminating status epilepticus and is superior to diazepam (59.1% vs 42.6% success rate) 1
  • May repeat once after at least 1 minute if seizures continue (maximum 2 doses) 3, 2
  • Have airway equipment immediately available before administration—respiratory depression can occur 1

Alternative Routes When IV Access Unavailable

  • IM midazolam 0.2 mg/kg (maximum 6 mg) achieves therapeutic levels within 5-10 minutes and shows 73.4% seizure cessation 1, 3
  • Intranasal midazolam has onset within 1-2 minutes with peak effect at 3-4 minutes 1
  • Rectal diazepam 0.5 mg/kg if other routes not feasible 1
  • Never use IM diazepam due to erratic absorption 1

Stage 2: Second-Line Treatment (5-20 minutes)

If seizures persist after adequate benzodiazepine dosing, immediately administer one of the following second-line agents—do not delay for neuroimaging: 1

Preferred Second-Line Options (Choose One)

Valproate 20-30 mg/kg IV over 5-20 minutes:

  • 88% efficacy with 0% hypotension risk—superior safety profile to phenytoin 1
  • Minimal cardiovascular effects make this the safest option 1
  • Avoid in women of childbearing potential due to teratogenicity 1

Levetiracetam 30 mg/kg IV (maximum 2,500-3,000 mg) over 5 minutes:

  • 68-73% efficacy with minimal adverse effects 1, 4
  • No cardiac monitoring required 1
  • Excellent choice for elderly patients or those with cardiac disease 1
  • Requires renal dose adjustment in kidney dysfunction 1

Fosphenytoin 20 mg PE/kg IV at maximum rate of 50 mg/min:

  • 84% efficacy but 12% hypotension risk 1
  • Requires continuous ECG and blood pressure monitoring 1
  • Traditional agent with 95% of neurologists recommending it for benzodiazepine-refractory seizures 1
  • Faster administration and less cardiovascular toxicity than phenytoin 1

Phenobarbital 20 mg/kg IV over 10 minutes:

  • 58.2% efficacy as initial second-line agent 1
  • Higher risk of respiratory depression and hypotension due to vasodilatory effects 1, 3
  • Reserve for cases where other agents contraindicated 1

Critical Simultaneous Actions During Stage 2

  • Search for and treat underlying causes: hypoglycemia, hyponatremia, hypoxia, drug toxicity, CNS infection, ischemic stroke, intracerebral hemorrhage, withdrawal syndromes 1
  • Maintain euvolemia with IV fluid resuscitation to prevent hypotension 1
  • Continue continuous vital sign monitoring 1

Stage 3: Refractory Status Epilepticus (20-40 minutes)

Refractory SE is defined as seizures continuing despite benzodiazepines and one second-line agent—initiate continuous EEG monitoring at this stage. 1, 4

Third-Line Anesthetic Agents (Choose One)

Midazolam infusion (First-choice anesthetic):

  • Loading dose: 0.15-0.20 mg/kg IV 1, 3
  • Continuous infusion: 1 mg/kg/min, titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min 1
  • 80% overall success rate with 30% hypotension risk 1
  • Lower hypotension risk than pentobarbital (30% vs 77%) 1
  • Prepare for mechanical ventilation and respiratory support 1

Propofol:

  • Loading dose: 2 mg/kg bolus 1
  • Continuous infusion: 3-7 mg/kg/hour 1, 4
  • 73% seizure control with 42% hypotension risk 1
  • Requires mechanical ventilation but shorter ventilation time than barbiturates (4 days vs 14 days) 1
  • Continuous blood pressure monitoring essential 1
  • Useful in already-intubated patients without hypotension 1

Pentobarbital (Most effective but highest risk):

  • Loading dose: 13 mg/kg 1
  • Continuous infusion: 2-3 mg/kg/hour 1
  • 92% efficacy—highest seizure control rate 1
  • 77% hypotension risk requiring vasopressors 1
  • Prolonged mechanical ventilation (mean 14 days) 1
  • Reserve for cases failing midazolam or propofol 1

Essential Monitoring for Refractory SE

  • Continuous EEG monitoring to guide titration and achieve seizure suppression 1, 4
  • Continuous blood pressure monitoring with vasopressors immediately available 1
  • Mechanical ventilation capability required 1
  • Load with long-acting anticonvulsant (phenytoin/fosphenytoin, valproate, levetiracetam, or phenobarbital) during anesthetic infusion before tapering 1

Stage 4: Super-Refractory Status Epilepticus (>24 hours)

Super-refractory SE is defined as seizures reemerging after weaning or continuing despite propofol or midazolam. 4

Additional Treatment Options

  • Ketamine: 0.45-2.1 mg/kg/hour infusion 1

    • 64% efficacy when administered early (within 3 days), drops to 32% when delayed 1
    • Acts on NMDA receptors—mechanistically distinct from GABA-ergic agents 1
    • Use with caution in patients with depleted catecholamine reserves 1

  • Consider additional non-sedating ASM: lacosamide, brivaracetam 4

  • Evaluate for autoimmune encephalitis and initiate immunotherapy if indicated 4

  • Continuous EEG monitoring for minimum 48 hours after complete anesthetic discontinuation 1

Maintenance Therapy After Seizure Control

For Convulsive Status Epilepticus

  • Lorazepam 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 2
  • Levetiracetam 30 mg/kg IV every 12 hours OR increase prophylaxis dose by 10 mg/kg (to 20 mg/kg) IV every 12 hours (maximum 1,500 mg) 1, 2
  • Phenobarbital 1-3 mg/kg IV every 12 hours if used in acute management 2

For Non-Convulsive Status Epilepticus

  • Lorazepam 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 2
  • Levetiracetam 15 mg/kg (maximum 1,500 mg) IV every 12 hours 1, 2
  • Phenobarbital 1-3 mg/kg IV every 12 hours if used in acute management 2

Critical Pitfalls to Avoid

  • Never use neuromuscular blockers alone (e.g., rocuronium)—they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 1
  • Do not skip to third-line agents until benzodiazepines and a second-line agent have been tried 1
  • Do not delay anticonvulsant administration for neuroimaging in active status epilepticus 1
  • Avoid attributing altered mental status solely to post-ictal state—obtain urgent EEG if patient does not awaken within expected timeframe, as nonconvulsive SE occurs in >50% of cases 1
  • Never administer phenytoin with glucose-containing solutions—causes precipitation 3
  • Do not use flumazenil in patients receiving benzodiazepines for seizure control—may precipitate seizure recurrence 3, 2

Special Monitoring Considerations

  • Continuous EEG monitoring throughout tapering process and for at least 24-48 hours after discontinuation—breakthrough seizures occur in >50% of patients and are often only detectable by EEG 1
  • Monitor for Lance-Adams syndrome (generalized myoclonus with epileptiform discharges)—may be compatible with good outcome and should not be treated overly aggressively 1
  • Prepare for respiratory support regardless of administration route—apnea can occur up to 30 minutes after last benzodiazepine dose 1
  • Risk of respiratory depression increases substantially when benzodiazepines combined with opioids or other sedatives 1, 3

Pediatric Considerations

  • Lorazepam 0.1 mg/kg IV (maximum 2 mg) for convulsive SE; 0.05 mg/kg IV (maximum 1 mg) for non-convulsive SE 3, 2
  • Levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) as second-line 2
  • Phenobarbital 10-20 mg/kg IV (maximum 1,000 mg) as alternative second-line 2
  • Fosphenytoin maximum infusion rate: 1-3 mg/kg/min or 50 mg/min, whichever is slower 1, 3
  • Neonates and young infants have altered phenytoin pharmacokinetics—phenobarbital preferred 3
  • Monitor heart rate and reduce phenytoin infusion speed if it decreases by 10 beats per minute 3

References

1
Guideline

Status Epilepticus Treatment Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Management of Status Epilepticus in Children

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Pediatric Seizure Treatment Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

4
Research

Status epilepticus in the ICU.

Intensive care medicine, 2024

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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