Status epilepticus

Definition / recognition: Continuous seizure ≥5 minutes (or recurrent without recovery) is status epilepticus. This patient is in established status (~12 min) and has already received one prehospital benzodiazepine — the clock continues; do not restart from zero.^[1]

Resuscitation (parallel with drugs):

• Airway protection, high-flow oxygen, suction, recovery position when feasible; prepare for RSI.
• IV access, monitoring, capillary glucose already normal — document; still send Na, Ca, Mg, gas, AED levels if known epilepsy, β-hCG if applicable, tox screen.
• Thiamine 100 mg IV if alcohol/malnutrition risk before/with glucose when glucose is low (not required here for hypoglycaemia treatment).

Pharmacological ladder:

1. Benzodiazepine: Give lorazepam 4 mg IV now (counts as second benzo exposure after IM midazolam). Do not give a third benzodiazepine if still seizing — move on. If no IV, further IM midazolam only if a second benzo has not yet been given.^[1]
2. Second-line ASM (ESETT-equivalent agents) — choose one:^[1][2]
   • Levetiracetam 60 mg/kg IV (max ~4.5 g) over 10–15 min, or
   • Fosphenytoin 20 mg PE/kg IV (max rate 150 mg PE/min), or
   • Valproate 30 mg/kg IV (avoid in pregnancy).
3. Refractory (continues ~30 min despite benzo + second-line): RSI, ventilate, continuous anaesthetic infusion (propofol or midazolam or thiopentone) titrated toward burst-suppression on EEG; ICU and continuous EEG.^[1]

Cause in parallel (AIMS): acute structural (CT when stable), idiopathic/known epilepsy non-adherence, metabolic, substance/withdrawal; treat specifically (e.g. pyridoxine for INH).^[1]

Disposition: Neurology/ICU for refractory; observe and first-fit/epilepsy pathway if terminates and wakes.^[1]