Synopsis
Treat convulsive status epilepticus from the five-minute threshold with parallel physiological support and cause correction, escalate promptly after two benzodiazepine doses, and recognise non-convulsive status when consciousness does not recover.
- Use the operational five-minute threshold because spontaneous termination becomes less likely and neuronal, respiratory, metabolic and systemic injury accumulates as convulsions continue.
- Protect from injury, position and suction when feasible, give high-concentration oxygen if hypoxaemic, attach monitoring, obtain intravenous or intraosseous access and check capillary glucose immediately.
- Give first-line benzodiazepine promptly: intravenous lorazepam when resuscitation facilities and access are available, or buccal midazolam or rectal diazepam when they are not, following the individual plan or local protocol.
Key red flags
Continuous generalised convulsive activity at five minutes or recurrent convulsions without meaningful recovery meets the emergency treatment threshold and should be announced with elapsed time.
Investigation priorities
Detect a rapidly reversible cause and quantify respiratory and circulatory compromise during treatment.
Management branches
A convulsive seizure reaches five minutes or repeats without recovery.
- 1. Call the emergency team, state seizure duration, protect airway and cervical spine as relevant, monitor ABCDE and check capillary glucose.
- 2. Give intravenous lorazepam if access and resuscitation facilities are present, otherwise use buccal midazolam or rectal diazepam according to plan and protocol.
Key medicines
Intravenous lorazepamA common adult protocol uses 0.1 mg/kg intravenously up to 4 mg, with one repeat dose after 5–10 minutes if convulsions continue; use the current local algorithm.
Intravenous levetiracetamMany UK emergency protocols use 60 mg/kg up to 4.5 g infused over about 10 minutes after two benzodiazepine doses; confirm dose and infusion with the local formulary.