Status Epilepticus — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Recognize & initial stabilization (0–5 min)
   Does it meet SE criteria and is initial stabilization done? (Convulsive SE = lasting ≥5 min, or consciousness not recovered between two seizures. Initial stabilization: ABC, oxygen, monitoring, IV access, check glucose (low → 50% dextrose + thiamine), check electrolytes/calcium/magnesium/toxicology/antiseizure-drug levels, find the trigger.)
   • Meets it → first-line drug → First-line · benzodiazepine (5–20 min)
   • <5 min or self-terminated → SE not met → observe
2. [End] SE not met → observe
   Does not meet SE criteria: monitor, find the trigger (fever, hypoglycemia, electrolyte disturbance, drug withdrawal), assess as a single seizure and repeat EEG if needed; have a plan ready for recurrence.
3. [Decision] First-line · benzodiazepine (5–20 min)
   Did seizures stop after an adequate first-line benzodiazepine? (Adequate single dose: IV lorazepam 0.1 mg/kg (max 4 mg per dose, may repeat once); if no IV access, IM midazolam 10 mg (>40 kg) / 5 mg (13–40 kg); or IV diazepam 0.15–0.2 mg/kg (max 10 mg). Underdosing is the most common cause of failure.)
   • Stopped → Seizures stopped · maintenance
   • Not stopped → second-line → Second-line · antiseizure drug (20–40 min)
4. [Decision] Second-line · antiseizure drug (20–40 min)
   Did seizures stop after a second-line antiseizure drug? (Choose one adequate IV dose: levetiracetam 60 mg/kg (max 4500 mg), valproate 40 mg/kg (max 3000 mg), or fosphenytoin 20 mg PE/kg (max 1500 mg). The ESETT trial showed all three are equally effective.)
   • Stopped → Seizures stopped · maintenance
   • Not stopped → refractory → Refractory SE (40–60 min)
5. [End] Refractory SE (40–60 min)
   Refractory SE (failed two adequate drug classes): intubate + continuous-EEG-monitored anesthesia — IV infusion of midazolam / propofol / pentobarbital, titrated to seizure cessation or burst-suppression; transfer to ICU. Recurrence after >24 h of anesthesia is super-refractory. Throughout, investigate and treat the cause (encephalitis, stroke, metabolic, toxic, autoimmune, etc.).
6. [End] Seizures stopped · maintenance
   Seizures stopped: maintain an antiseizure drug to prevent recurrence; monitor continuously and watch for non-convulsive SE (EEG if consciousness does not recover); identify and treat the cause.

Source guidelines & references

• American Epilepsy Society (AES) 2016 guideline on treatment of convulsive status epilepticus. Epilepsy Curr 2016
• ESETT three-drug comparison trial (levetiracetam / valproate / fosphenytoin). NEJM 2019

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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