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.
- If convulsions continue, a second benzodiazepine dose can be given after the protocol interval; after two adequate doses, move to intravenous levetiracetam, phenytoin or sodium valproate with expert guidance.
- Do not let repeated small benzodiazepine doses consume the treatment window. Cumulative respiratory depression and failure to progress are common medication errors in prolonged seizures.
- Refractory status persisting after an appropriate benzodiazepine and second-line medicine needs critical care, anaesthetic treatment and continuous EEG according to a specialist protocol.
- Search for causes in parallel: non-adherence, stroke, infection, hypoglycaemia, sodium disturbance, alcohol or drug withdrawal, toxicity, eclampsia, trauma and autoimmune encephalitis all require mechanism-specific treatment.
- For eclampsia, intravenous magnesium sulfate is the first-line anticonvulsant: use the obstetric regimen rather than substituting diazepam, phenytoin or a routine status-epilepticus load.
- Persistent impaired consciousness after motor activity stops may be postictal, sedative-related or non-convulsive status; serial examination and urgent EEG help distinguish these pathways.
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.
Persistent eye deviation, eyelid twitching, facial jerks or rhythmic distal movement after major convulsions stop can represent continuing seizure activity rather than recovery.
Unexplained prolonged confusion, fluctuating responsiveness, behavioural change or coma, especially after a convulsion or in acute brain illness, warrants urgent EEG and neurological review.
Hypoxia, hypercapnia, aspiration, hypotension, hyperthermia, acidosis, rhabdomyolysis and hyperkalaemia can emerge during prolonged convulsions and need concurrent resuscitative treatment.
Fever with meningism, pregnancy-associated hypertension, focal deficit, head trauma, severe hyponatraemia or toxic exposure directs an additional time-critical pathway alongside seizure termination.
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.
- 3. Document drug, dose and exact time, reassess ventilation and circulation, obtain IV or IO access and send urgent cause-directed blood tests.
- 4. If seizure activity continues after the specified interval, give one further adequate benzodiazepine dose while preparing second-line therapy and critical-care support.