🚨 Status Epilepticus

Status epilepticus is defined as a seizure lasting longer than 5 minutes, or recurrent seizures without full recovery of consciousness between episodes. It is a neurological emergency associated with significant morbidity and mortality if not promptly treated.

Continuous tonic-clonic movements for >5 minutes, or repeated seizures without regaining consciousness. Can also present as non-convulsive status epilepticus (e.g., altered mental status, subtle motor signs) which is harder to recognise. Look for signs of injury from falls.

Prioritise ABCDE. Protect the airway, administer high-flow oxygen, and establish IV access. Assess for injuries sustained during the seizure. Check blood glucose immediately. Note seizure type, duration, and any precipitating factors.

Seizure duration exceeding 5 minutes, failure to respond to initial benzodiazepine treatment, signs of cerebral oedema or herniation, persistent hypoxia or hypotension. These indicate refractory status epilepticus requiring advanced interventions.

Bedside: Capillary blood glucose, vital signs, ECG. Bloods: FBC, U&Es, LFTs, calcium, magnesium, phosphate, toxicology screen, antiepileptic drug levels, arterial blood gas. Imaging: CT head if new onset, focal signs, or suspected structural cause. EEG for non-convulsive status.

First-line treatment involves rapid administration of a benzodiazepine (e.g., lorazepam IV, midazolam buccal/IM, diazepam rectal). If seizures persist, second-line agents (e.g., phenytoin, levetiracetam, valproate) should be given. Maintain airway, oxygenation, and circulatory support. Treat underlying causes.

Failure to respond to first-line benzodiazepines. Seizure duration exceeding 10-15 minutes. Any signs of cardiorespiratory compromise or neurological deterioration. Discuss with neurology and critical care specialists for refractory status epilepticus.

The 5-minute threshold for status epilepticus is crucial for intervention. Benzodiazepines are first-line due to rapid action. Always check blood glucose as hypoglycaemia can mimic or precipitate seizures. Non-convulsive status epilepticus is a diagnostic challenge and requires EEG.