ICU · Neurocritical care / seizures
Status Epilepticus & Refractory Status Epilepticus
Also known as Status epilepticus · Convulsive status epilepticus · Refractory status epilepticus · Super-refractory status epilepticus · Non-convulsive status epilepticus · ESETT · RAMPART · Anti-NMDA receptor encephalitis · Burst suppression
Status epilepticus (SE) is a continuous seizure lasting more than 5 minutes, or two or more seizures without full recovery between them — a neurological emergency where the longer the seizure lasts, the harder it becomes to terminate and the worse the outcome. First line is a benzodiazepine (lorazepam 4 to 8 mg IV, or intramuscular midazolam when there is no line). Second line is levetiracetam 60 mg/kg, fosphenytoin 20 mg PE/kg, or valproate 40 mg/kg (ESETT showed all three equivalent, terminating the seizure with improved alertness by 60 minutes in about half). Refractory SE (failure of first and second line) requires anaesthetic intubation with propofol, midazolam, ketamine, or thiopent infusions titrated to burst suppression on continuous EEG. Non-convulsive SE and autoimmune causes such as anti-NMDA receptor encephalitis must not be missed.
Checked against its sources on 23 Sept 2026
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Red flags
- A seizure lasting more than 5 minutes is status epilepticus — treat it, do not wait
- Subtle SE (eye deviation, nystagmus, facial twitching) after overt SE means the seizure has not stopped
- Failure to regain consciousness after convulsive SE demands continuous EEG to exclude non-convulsive SE
- Hypoglycaemia, hyponatraemia, and drug withdrawal are reversible causes — check the glucose first
- Refractory SE requires anaesthetic intubation — call for help and prepare the propofol or midazolam infusion early
- A young patient with new psychiatric symptoms and seizures has anti-NMDA receptor encephalitis until proven otherwise
Meet the patient
A 24-year-old man is brought in by ambulance, still convulsing — the jerking started six minutes ago at the bus stop. He has no IV access, the paramedics have oxygen on his face, and his mother is shouting that he has never done this before. The clock on the wall is the most important instrument in the room.[5]
The single question this patient forces is the question every SE stem turns on: the seizure has crossed five minutes — what do you do in the next ten, and what do you do if it does not stop? Hold that question and the whole ladder below falls into place.[5]
References18ShowHide
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- [2]Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus N Engl J Med, 2012.PMID 22335736
- [3]Treiman DM, Meyers PD, Walton NY, et al. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group N Engl J Med, 1998.PMID 9738086
- [4]Alldredge BK, Gelb AM, Isaacs SM, et al. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus N Engl J Med, 2001.PMID 11547716
- [5]Trinka E, Cock H, Hesdorffer D, et al. A definition and classification of status epilepticus--Report of the ILAE Task Force on Classification of Status Epilepticus Epilepsia, 2015.PMID 26336950
- [6]Trinka E, Leitinger M. Management of Status Epilepticus, Refractory Status Epilepticus, and Super-refractory Status Epilepticus Continuum (Minneap Minn), 2022.PMID 35393970
- [7]Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus Neurocrit Care, 2012.PMID 22528274
- [8]Claassen J, Mayer SA, Kowalski RG, Emerson RG, Hirsch LJ. Detection of electrographic seizures with continuous EEG monitoring in critically ill patients Neurology, 2004.PMID 15159471
- [9]Titulaer MJ, McCracken L, Gabilondo I, et al. Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis: an observational cohort study Lancet Neurol, 2013.PMID 23290630
- [10]Dalmau J, Armangué T, Planagumà J, et al. An update on anti-NMDA receptor encephalitis for neurologists and psychiatrists: mechanisms and models Lancet Neurol, 2019.PMID 31326280
- [11]Rosati A, De Masi S, Guerrini R. Ketamine for Refractory Status Epilepticus: A Systematic Review CNS Drugs, 2018.PMID 30232735
- [12]Sutter R, Kaplan PW, Marsch S, et al. Early predictors of refractory status epilepticus: an international two-center study Eur J Neurol, 2015.PMID 25104078
- [13]Vossler DG, Bainbridge JL, Boggs JG, et al. Treatment of Refractory Convulsive Status Epilepticus: A Comprehensive Review by the American Epilepsy Society Treatments Committee Epilepsy Curr, 2020.PMID 32822230
- [14]Meierkord H, Boon P, Engelsen B, et al. EFNS guideline on the management of status epilepticus in adults Eur J Neurol, 2010.PMID 20050893
- [15]Kam PC, Cardone D Propofol infusion syndrome Anaesthesia, 2007.PMID 17567345
- [16]DeLorenzo RJ, Hauser WA, Towne AR, et al. A prospective, population-based epidemiologic study of status epilepticus in Richmond, Virginia. Neurology, 1996.PMID 8780085
- [17]Dalmau J, Gleichman AJ, Hughes EG, et al. Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies. Lancet Neurol, 2008.PMID 18851928
- [18]Shorvon S, Ferlisi M. The outcome of therapies in refractory and super-refractory convulsive status epilepticus and recommendations for therapy. Brain, 2012.PMID 22577217