Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Status epilepticus emergency treatment
Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Convulsive status epilepticus
A convulsive seizure continuing for five minutes or recurrent convulsions without recovery is a time-critical airway, breathing, circulation and neurological emergency.
Action: Start the clock, call senior and resuscitation help, use ABCDE with monitoring and glucose, give one first-line benzodiazepine and move through the local paediatric algorithm without exceeding two benzodiazepine doses.
Purpose and principles
Deliver a timed paediatric convulsive-status pathway from five minutes onward, correct reversible causes, escalate safely after two benzodiazepine doses and prepare early for anaesthesia and critical care.
Convulsive status is both a neurological and systemic emergency. Prolonged synchronous motor activity increases oxygen and glucose demand, catecholamines, lactate and temperature, while airway obstruction, hypoventilation and aspiration reduce supply. Early treatment is more effective because inhibitory receptor trafficking changes as seizures continue.
At arrival, announce elapsed time and allocate roles. Remove hazards, use jaw positioning and suction, give high-flow oxygen only when required, attach ECG, saturation and blood-pressure monitoring and check glucose immediately. Obtain intravenous or intraosseous access, but do not delay a non-intravenous first benzodiazepine while struggling for a cannula.
The first-line phase consists of one benzodiazepine dose, reassessment and one repeat if still convulsing after five minutes. Buccal midazolam is practical without access; IV lorazepam is appropriate with access and resuscitation support. A prehospital or parent dose counts. Excess benzodiazepine causes respiratory failure and delays more effective second-line treatment.
Indications, selection and cautions
Convulsive status threshold
Bilateral tonic-clonic activity continuing at five minutes, or recurrent convulsions without recovery, triggers the emergency algorithm.
Subtle ongoing seizure
Rhythmic eye deviation, facial twitching, nystagmoid movements or unexplained unresponsiveness after major jerking stops may reflect continuing electrographic status.
Respiratory compromise
Cyanosis, weak respiratory effort, aspiration, falling saturation or rising carbon dioxide requires active airway and ventilation support.
Raised intracranial pressure
Unequal pupils, hypertension with bradycardia, focal deficit or deteriorating consciousness after seizure control demands urgent neuroimaging and specialist care.
Toxic metabolic context
Abnormal glucose, temperature, pupil pattern, odour, access to medicines or electrolyte loss points toward a reversible provoking cause.
Red flags requiring action
Treat at five minutes; waiting for the older 30-minute definition increases treatment resistance and systemic harm.
Respiratory depression, cyanosis, aspiration, shock or severe acidosis requires immediate airway and critical-care support alongside seizure treatment.
Count benzodiazepine doses already given by carers or ambulance staff because more than two increases respiratory depression without reliably ending established status.
Assessment before treatment
01Immediate capillary glucoseFirst step
Why
Detect a rapidly reversible driver of ongoing neuronal energy failure.
Interpretation and limitations
Treat a low value immediately with the paediatric hypoglycaemia protocol while continuing seizure control.
02Bedside blood gas and electrolytes
Why
Assess ventilation, lactate, sodium, ionised calcium, potassium and severe acid-base disturbance.
Interpretation and limitations
Correct clinically important abnormalities carefully; postictal lactate should fall, whereas persistent acidosis suggests ongoing compromise.
03Targeted infection and toxicology tests
Why
Identify sepsis, meningitis, encephalitis, ingestion or medicine non-adherence as the precipitant.
Interpretation and limitations
Cultures and samples must not delay antibiotics, aciclovir or antidotal treatment when clinical suspicion is high.
04Urgent neuroimaging after stabilisation
Why
Detect haemorrhage, stroke, mass, hydrocephalus or trauma when focal or pressure features are present.
01Zero to five minutesStabilise and find reversible causesFirst stepA child is actively convulsing on first clinical contact.+
1Start timing, summon help, protect airway and attach cardiorespiratory monitoring.
2Check glucose and obtain intravenous or intraosseous access without delaying rescue medicine.
3Treat hypoxaemia, hypoglycaemia, shock and a suspected acute cause in parallel.
02Five to ten minutesGive first benzodiazepineConvulsions continue at the five-minute treatment threshold.+
1Give buccal midazolam without access or intravenous lorazepam when access is secure.
2Confirm the exact weight-based dose and count any dose given before arrival.
Regimens, contraindications and interactions
Preferred first-line non-intravenous benzodiazepine when convulsive status begins and intravenous access is unavailable.
Buccal midazolam
Give 0.3 mg/kg buccally, maximum 10 mg, or the prescribed licensed age-banded dose; reassess after five minutes and do not exceed two total benzodiazepine doses including prehospital treatment.
Support airway and breathing, record previous rescue doses, avoid repeated dose stacking and remember that respiratory depression may reflect both status and benzodiazepine exposure.
First-line benzodiazepine when intravenous access is established and resuscitation facilities are immediately available.
Intravenous lorazepam
Give 0.1 mg/kg intravenously, maximum 4 mg, over about one minute; if convulsions persist after five minutes, one repeat may be given provided no other two-dose total has already been reached.
Continuous respiratory and cardiovascular observation is required; accumulation causes apnoea and hypotension, so move to second-line therapy after two adequate benzodiazepine doses.
Second-line antiseizure therapy with rapid preparation and relatively limited cardiovascular depression.
Intravenous levetiracetam
Give 40 mg/kg intravenously, maximum 2.5 g, over 5 minutes after two benzodiazepine doses, unless the current regional paediatric algorithm specifies an updated regimen.
Confirm dose and previous therapy, adjust subsequent maintenance for renal impairment and watch for agitation or somnolence; failure requires immediate refractory-status escalation.
Complications, monitoring and follow-up
Continuously record airway patency, respiratory effort, saturation, ECG, blood pressure and temperature throughout active treatment.
Document seizure onset and every medicine time, dose, route and response on one visible timeline.
Repeat glucose, gas and electrolytes according to abnormalities and ongoing critical illness.
Assess for continued subtle motor or electrographic seizure when consciousness does not recover after convulsions stop.
After phenytoin monitor rhythm, blood pressure and infusion site; after anaesthetic treatment monitor ventilation and haemodynamics in critical care.
Before discharge or transfer, identify the precipitant, reconcile usual antiseizure medicines and update the emergency rescue plan.
Special situations
The clock is treatment
Every handover should state elapsed seizure time because treatment resistance increases while teams repeat assessment without acting.
Prehospital doses count
A parent or ambulance benzodiazepine is pharmacologically real and must be included in the maximum two-dose total.
Access should not delay rescue
Buccal midazolam permits prompt first-line treatment while another clinician establishes intravenous or intraosseous access.
Motor quiet is not recovery
Paralysis, exhaustion or partial treatment can stop visible jerking while non-convulsive electrographic status continues.
Cause and seizure run together
Antibiotics, aciclovir, glucose or toxin treatment should proceed alongside rather than after the antiseizure sequence.
Common pitfalls
01
Waiting beyond five minutes before starting treatment.
02
Giving repeated benzodiazepines without counting prehospital doses.
03
Delaying buccal treatment while repeatedly attempting intravenous access.
04
Infusing phenytoin without ECG and blood-pressure monitoring.
05
Choosing valproate without hepatic, mitochondrial and reproductive safety review.
06
Waiting for second-line failure before calling anaesthesia.
07
Assuming cessation of jerking proves electrographic seizure control.
Practice
Two practice questions
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Question 1 of 2
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Paediatrics and child healthOriginal SBA
Persistent seizure after rescue
A child remains convulsing after two correctly dosed benzodiazepines, including one given by ambulance staff. What is the safest next treatment step?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Second-line intravenous therapy follows two benzodiazepines. RCPCH and NICE pathways include levetiracetam, phenytoin or sodium valproate; the local network algorithm determines exact sequencing. Levetiracetam has few haemodynamic interactions. Phenytoin needs ECG and blood-pressure monitoring and a controlled infusion. Valproate is unsuitable in important hepatic or suspected mitochondrial disease and carries major reproductive restrictions.
If convulsions continue after a second-line drug, obtain immediate expert guidance for another second-line option or rapid-sequence induction and critical-care management according to the pathway. Thiopental, propofol, midazolam infusion or other anaesthetic therapy requires ventilation, haemodynamic support and EEG-directed specialist care. Consider pyridoxine-dependent seizures in refractory young infants through specialist advice.
Investigate in parallel rather than pausing treatment. Blood gas, electrolytes, calcium, magnesium, renal and liver tests, FBC, cultures and toxicology are selected from context. Take antiseizure levels when meaningful but do not wait for them. Suspected bacterial meningitis needs immediate antibiotics; suspected encephalitis needs IV aciclovir. Image and perform lumbar puncture only after stabilisation and when safe.
Key points
Convulsive status treatment starts when a seizure reaches five minutes, or earlier if repeated seizures occur without neurological recovery.
First actions are timekeeping, help, airway positioning and suction readiness, oxygen for hypoxaemia, cardiorespiratory monitoring, vascular access and capillary glucose.
Give buccal or intranasal midazolam when intravenous access is unavailable, or intravenous lorazepam when access and resuscitation facilities are present.
Reassess after five minutes and give only one further benzodiazepine dose if convulsions continue, including any dose already given before arrival.
After two adequate benzodiazepine doses, move promptly to an intravenous second-line drug: levetiracetam, phenytoin or sodium valproate under the current local algorithm.
NICE notes that levetiracetam may be quicker to administer and have fewer adverse effects than the alternatives, but choice considers prior therapy, organ disease, interactions and local expertise.
Prepare senior anaesthetic and paediatric intensive-care support while the second-line infusion is being given, not after it fails.
Refractory convulsive status requires specialist anaesthetic therapy, ventilation and continuous EEG where available; visible jerking may stop while electrographic seizures continue.
Hypoglycaemia, electrolyte disturbance, meningitis, encephalitis, poisoning, trauma and missed antiseizure medicines must be identified and treated in parallel.
Persistent focal onset, unequal pupils or failure to recover after motor activity stops raises haemorrhage, stroke, mass or ongoing non-convulsive status.
Infants, children with mitochondrial disease and those with liver disease need specialist modification of second-line medicine choice.
Why
Detect non-convulsive status and guide anaesthetic treatment when consciousness fails to recover.
Interpretation and limitations
Electrographic seizure activity can persist after paralysis or cessation of visible convulsions and requires specialist interpretation.
3
Reassess breathing and seizure activity after five minutes and give one final benzodiazepine dose if required.
03After two dosesUse intravenous second-line therapySecond lineConvulsions persist after two adequate benzodiazepine doses.+
1Call anaesthesia and critical care and select levetiracetam, phenytoin or valproate using the local algorithm.
2Use the correct infusion rate and haemodynamic monitoring for the selected drug.
3Review organ disease, mitochondrial risk, interactions and prior antiseizure therapy without delaying treatment.
04RefractorySecure airway and suppress seizuresSecond lineConvulsions persist after appropriate second-line intravenous treatment.+
1Proceed through the network refractory-status plan with paediatric neurology and intensive care.
2Use rapid-sequence induction, ventilation and specialist anaesthetic infusion when indicated.
3Arrange EEG monitoring and continue investigation and treatment of the precipitating cause.
Alternative second-line sodium-channel therapy after two benzodiazepine doses, especially when syndrome and prior treatment support it.
Intravenous phenytoin
Give 20 mg/kg intravenously, maximum 2 g, through a controlled infusion no faster than 1 mg/kg/minute with continuous ECG and blood-pressure monitoring; use the regional paediatric protocol.
Hypotension, bradyarrhythmia, tissue injury and dosing or concentration errors are important; avoid in selected generalised epilepsies and consider interactions and cardiac disease.
Alternative broad-spectrum second-line treatment where the seizure syndrome and individual safety profile make it appropriate.
Intravenous sodium valproate
Give 40 mg/kg intravenously, maximum 3 g, over about 5 minutes only through the current specialist status protocol and after checking key hepatic and mitochondrial contraindications.
Avoid in significant liver disease, pancreatitis and suspected POLG-related mitochondrial disease; follow current MHRA reproductive restrictions and specialist approval requirements.
Treat glucose, electrolytes, sepsis, encephalitis, toxin exposure and antiseizure-medicine non-adherence simultaneously without interrupting the timed pathway.
Record exact seizure start, every drug, dose, route and time because dosing errors and hidden prehospital benzodiazepines are major preventable harms.