Status epilepticus
Five minutes of seizure is too long — treat by the clock. Protect the airway, check the glucose, give a benzodiazepine at 5 minutes, repeat once, move to a second-line drug, and call anaesthetics if it continues. Look for the cause while you treat. Built for revision, not live patient decisions.
Settle them, and check the basics
treat by the clockRed flags — what each should make you think
Write down the time each drug was given. Status is managed against the clock, and in the stress of resus it's easy to give a third benzodiazepine or wait too long before the second-line drug. Two doses of benzodiazepine, then move on.
The timeline (NICE NG217 / Resus Council UK)
- 0ABC, oxygen, glucose
- 5′First benzodiazepine
- 10′Repeat once
- 20′Second-line drug
- 40′Anaesthesia
- B1Thiamine
Understand the patient
find the causeCommon causes
- Known epilepsy: missed doses, low levels, intercurrent illness, alcohol, sleep deprivation
- Alcohol withdrawal
- Metabolic: hypoglycaemia, hyponatraemia, hypocalcaemia, hypomagnesaemia
- Infection: meningitis, encephalitis
- Structural: stroke, intracranial haemorrhage, tumour, trauma
- Toxins: tricyclics, cocaine, isoniazid, withdrawal from benzodiazepines
- Pregnancy: eclampsia
Non-epileptic attacks (functional seizures)
- Can look like status; often eyes tightly closed, resisting eye opening, side-to-side head movements, pelvic thrusting, long duration with fluctuating intensity
- Treating them with repeated benzodiazepines causes respiratory depression
- If in doubt, treat as epileptic and get senior/neurology help — don't label it lightly
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Continued seizure despite benzodiazepines and a second-line drug.
Clinical; EEG in ITU.
General anaesthesia and intubation, ITU, EEG monitoring.
Fever, rash, neck stiffness, confusion before the seizure.
Bloods, cultures, CT then LP when safe.
IV ceftriaxone ± amoxicillin, IV aciclovir.
Seizure after 20 weeks or postpartum, hypertension, proteinuria.
BP, urine PCR, bloods.
Magnesium sulfate, obstetric emergency team. See the pre-eclampsia page.
Diabetes, alcohol, SIADH, MDMA.
Glucose, U&E.
IV glucose; hypertonic saline for severe hyponatraemia.
Head injury, anticoagulants, focal signs, persisting low GCS.
CT head.
Neurosurgery as indicated.
Investigate — what to order, when, and what it tells you
test with a question in mindBedside
Bloods
Imaging
Other
How the plan comes together
disposition · handoverward / neurology
Seizures stopped, recovering, cause identified: neurology input, review antiseizure drugs, rescue medication plan.
ITU
Refractory status, intubated, or needing airway support.
Hand over: seizure duration, drugs and times, glucose, cause found.
ABC and glucose, benzodiazepine at 5 minutes, repeat once, second-line drug, then anaesthesia. Write down every time, and look for the cause while you treat. Nicely done getting here.
Clerking template
copy or downloadStatus epilepticus — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 12 knownFrequently asked questions
quick answersWhat are the red flags for status epilepticus?
- Seizure over 5 min, or repeated without recovery — think status epilepticus
- Low glucose — think hypoglycaemia
- Fever, neck stiffness, confusion — think meningitis / encephalitis
- Pregnant or postpartum — think eclampsia — magnesium
- Alcohol history — think withdrawal; give thiamine
- Overdose (e.g. tricyclics) — think toxic seizures
- Head injury — think intracranial bleed
What is the initial management of status epilepticus?
- ABC, oxygen, glucose — recovery position, suction, high-flow oxygen; treat glucose below 4 mmol/L
- First benzodiazepine — IV lorazepam (0.1 mg/kg, usually 4 mg in adults) or buccal midazolam / rectal diazepam if no IV access
- Repeat once — if still seizing 5–10 min after the first dose
- Second-line drug — levetiracetam, phenytoin or sodium valproate IV (avoid valproate in women and girls of childbearing potential if possible)
- Anaesthesia — refractory status: anaesthetist, intubation, ITU
- Thiamine — IV Pabrinex if alcohol use or malnutrition
Always alongside senior support and your local guideline.
What diagnoses must you not miss in status epilepticus?
- Refractory status — still seizing at 40 min
- Meningitis / encephalitis — fever + seizures
- Eclampsia — pregnant / postpartum
- Hypoglycaemia / hyponatraemia — metabolic
- Intracranial haemorrhage / trauma — focal · head injury
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for status epilepticus?
- Bedside — Immediately.
- Bloods — FBC, U&E, Ca, Mg, LFT, CK, antiseizure drug levels, toxicology.
- Imaging — First seizure, focal signs, trauma, anticoagulation, not recovering.
- Other — If infection suspected (after CT when indicated).
Admit or discharge: how is the plan decided for status epilepticus?
- Ward / neurology — Seizures stopped, recovering, cause identified: neurology input, review antiseizure drugs, rescue medication plan.
- Itu — Refractory status, intubated, or needing airway support.
Is there a clerking template for status epilepticus?
Yes — there is a clerking template for status epilepticus on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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