Status epilepticus is a seizure lasting 5 minutes or more, or repeated seizures without return to normal in between. The longer it lasts, the harder it is to stop and the higher the risk of brain injury, so treatment starts without waiting.
Key symptoms
- Continuous jerking of the limbs for 5 minutes or more
- Repeated seizures without waking up between them
- Unresponsiveness, drooling, tongue biting and incontinence
- Subtle twitching of the face or eyes with coma (nonconvulsive status)
- Fever, headache or drug use before the seizure
What you find on exam
- Airway, breathing and oxygen saturation
- Time since onset
- Blood glucose and temperature
- Signs of head injury, overdose or pregnancy
- Pupils, gaze deviation and one-sided weakness
Tests
- Point-of-care glucose right away
- Electrolytes, magnesium, calcium, toxicology and antiseizure drug levels
- CT head after stabilization
- EEG if the patient does not wake up
Treatment basics
- Protect the airway, give oxygen and turn the patient on the side when possible
- Benzodiazepine first: IM or intranasal midazolam, or IV lorazepam
- Glucose if blood sugar is low
- Second-line drug if seizures continue: levetiracetam, fosphenytoin or valproate
- Refractory status: intubation and anesthetic infusion; magnesium sulfate for eclampsia
Red flags
- Seizure lasting longer than 5 minutes
- Low oxygen or failing breathing
- Seizure in pregnancy or after a head injury
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Sources: NASEMSO National Model EMS Clinical Guidelines; NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations. Written by Making Synapses. Making Synapses is not affiliated with these organizations.