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  • Seizures persisting for more than 5 minutes, or seizure occurring during the postictal state from a prior seizure
  • Can be convulsive, non-convulsive, and/or refractory (continuing despite two intravenous agents)
  • Etiologies:
    • Known seizure disorder: poor compliance, drug interaction, lack of sleep
    • First seizure:
      • CVA, brain abscess or tumor, meningitis, head trauma
      • Metabolic (hypoglycemia, hyponatremia, hypocalcemia, porphyria)
      • Withdrawal (alcohol or drug), toxic (antidepressants, salicylates, ethylene glycol)

ABCs as needed, supplemental oxygen

Do not use bicarb to correct metabolic acidosis unless extreme (pH ≤ 6.9).

  • Is there a history of epilepsy? Is the patient on anti-epileptics? (Dose, obtain plasma levels)
  • Time of onset (when was the patient last seen normal?)
  • Drugs (agents that lower the seizure threshold; illicit drug abuse?)
  • Mental status (if not awake without twitches for more than 30 minutes, get EEG to rule out non-convulsive status; get CT-scan to rule out evolving brain lesion such as a stroke or hemorrhage)
  • Check for focal neurologic findings (if present, suggest underlying focal lesion)

  • Epilepsy or neurology consult
  • EEG – arrange for continuous monitoring if available
  • Call CT scanner and request a STAT head CT w/o (and possibly with, depending on clinical picture and suspicion of other lesion) contrast

CBC, electrolytes, liver function panel, urinary toxicology screen, anti-epileptic drug levels, PT/INR, PTT

LP if immunosuppressed, fever, or no etiology found


  • Thiamine 100 mg IV
  • 50 mL of D50 IV, unless finger stick >60
  • Lorazepam (Ativan) 0.1 mg/kg IV over 2 minutes (can repeat three times q5 minutes) OR 20 mg PR (if no IV access; can also use nasal midazolam 0.1–0.5 mg/kg) and Fosphenytoin (Cerebyx) 20 mg/kg IV (maximum of 150 mg/min) OR phenytoin (Dilantin) 20 mg/kg IV (maximum of 50 mg/min)
  • If Dilantin allergy, give valproic acid (Depacon) 20 mg/kg IV

SECONDARY: (if seizures persist, give one of the following)

  • Fosphenytoin (Cerebyx) 10 mg/kg IV (additional)
  • Valproic acid (Depacon) 40 mg/kg IV over 15 minutes
  • Levetiracetam (Keppra) 1000 mg IV (can repeat up to a maximum of 4000 mg)
  • Phenobarbital 20 mg/kg IV (maximum of 100 mg/min)

TERTIARY: (if seizures persist, intubate the patient, if not already done, and treat with one of the following)

  • Midazolam (Versed): load 0.2 mg/kg IV (maximum 2 mg/kg), then continuous drip 0.5–2.0 mg/kg/h
  • Propofol (Diprivan): load 1 mg/kg IV (maximum 15 mg/kg, avoid >5 mg/kg for >24 hours), then continuous drip 1–15 mg/kg/h
  • Titrate agents towards maximum until seizure cessation or EEG burst-suppression pattern

QUATERNARY: (if seizures persist clinically or on EEG)

  • Pentobarbital (Nembutal): load 5 mg/kg IV (maximum 10 mg/kg/h), then continuous drip 0.5–10 mg/kg/h

1. Prasad K, Al-Roomi K, Krishnan PR, et al. Anticonvulsant therapy for status epilepticus. Cochrane Database Syst Rev. 2005 Oct;(4):CD003723.   [PubMed: 16235337]
2. Treiman DM, Meyers PF, Walton ...

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