Convulsive status epilepticus is generally defined as a seizure lasting five minutes or more, or repeated seizures without recovery in between. Treatment is time-critical because benzodiazepine response falls the longer seizures continue.
First-line treatment is an adequately dosed benzodiazepine at five minutes — intravenous lorazepam or diazepam, or intramuscular or buccal midazolam without IV access — repeated once if needed. Underdosing is the commonest error. If seizures continue, a second-line agent such as levetiracetam, valproate or fosphenytoin should go in by about 20 to 30 minutes. Persisting status after that is refractory and usually needs anaesthetic agents and EEG monitoring in intensive care.
- Give a full-dose benzodiazepine at five minutes of continuous seizure activity.
- Use intramuscular or buccal midazolam if there is no IV access.
- Start a second-line agent by about 20–30 minutes if seizures persist.
- Check glucose early and give thiamine before glucose where malnutrition or alcohol use is possible.
- Arrange EEG when consciousness does not return, to detect non-convulsive status.
Why it matters
Delays and underdosing at the first step are what turn treatable status into refractory status.
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