Status epilepticus — ladder, ESETT and non-convulsive status

Why the clock matters: seizures become harder to terminate the longer they continue, so early treatment along the ladder is essential — confirm receptor-level timing against local epilepsy teaching; the held Continuum review covers established, refractory and super-refractory SE diagnosis and management.^[3]

ESETT: In established benzodiazepine-refractory SE, levetiracetam, fosphenytoin and valproate terminated seizures and maintained cessation in roughly 45–50% with no significant difference between agents. Choose by patient factors (haemodynamics, pregnancy, need for levels), not by perceived superiority.^[1]

This patient: failure to wake after motor seizure stops is non-convulsive status until proven otherwise. Look for subtle eyelid/facial twitching or nystagmoid movements. Urgent EEG (continuous if available); treat as ongoing SE — escalate along the ladder if EEG confirms ictal activity; protect airway; image for structural cause once safe — confirm NCSE specifics against local epilepsy protocol.^[3]

Refractory pathway: if EEG shows ongoing SE despite second-line, proceed per the local refractory-SE pathway with continuous EEG monitoring; confirm coma targets and cause work-up locally.^[3]