Either a single seizure >5 minutes or ≥2 seizures without a return to baseline in between
Differentiating convulsive seizures from non-epileptic events (“pseudoseizure”): See “Seizure without Status Epilepticus” chapter
Features that suggest non-epileptic/psychogenic event include moaning or talking throughout the event, “no-no” head shake, repetitive movements of opposing muscle groups, very arrhythmic or purposeful-looking movements, or seizures that have been ongoing for “hours”
Evaluation
Fingerstick glucose, BMP/CBC, and UDS
Consult Neurology
EEG (start with 2hr) to determine if it is seizure or not and for titration of medications
Consider a non-contrasted head CT. MRI cannot be obtained while EEG is attached
Up to half of pts presenting in status epilepticus have no history of seizure, so they need urgent head imaging, consideration for lumbar puncture, infectious and toxic workup, tox screen, and sometimes rheumatologic or paraneoplastic workup
If history of seizure or on antiseizure medications (ASMs) obtain trough levels
Management
ABCs! Start with benzos:
2 mg lorazepam IV then repeat q1-3 minutes up to 0.1 mg/kg OR
5 mg of diazepam IV every minute (takes longer to give diazepam so would give concurrent ASM) OR
10 mg IM midazolam if no IV access
After 2 rounds of benzos, would shift to anti-seizure medications if still in status (neurology should be contacted here if not already):
IV fosphenytoin 20 mg/kg
IV valproic acid 40 mg/kg
IV levetiracetam 60 mg/kg (up to 4.5g max)
If still seizing at this point, the pt will likely need intubation
These pts MUST be placed on EEG if they get paralyzed or sedated because convulsive status often continues as nonconvulsive status, which still damages the brain.
If still seizing, pts should be on midazolam, Propofol, or barbiturate infusions
Focal seizures, such as arm or face twitching with retained awareness do not always need to be treated to the point of initiating coma
