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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

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.

Synopsis

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 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.
  • 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.

Key red flags

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.

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.

Investigation priorities

01
Immediate capillary glucoseFirst step

Detect a rapidly reversible driver of ongoing neuronal energy failure.

Management branches

Zero to five minutesStabilise and find reversible causes

A child is actively convulsing on first clinical contact.

  1. Start timing, summon help, protect airway and attach cardiorespiratory monitoring.
  2. Check glucose and obtain intravenous or intraosseous access without delaying rescue medicine.
  3. Treat hypoxaemia, hypoglycaemia, shock and a suspected acute cause in parallel.

Key medicines

Buccal midazolamGive 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.
Intravenous lorazepamGive 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.
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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.

  • NICE NG217 Epilepsies GuidelineCommunity, hospital and refractory status epilepticus treatment choices.
  • BNFC Status EpilepticusUK paediatric rescue, intravenous loading and escalation regimens.
  • Medicines for Children Buccal MidazolamAge-banded rescue administration and family safety information.
  • NICE NG240 Meningitis GuidelineParallel antimicrobial assessment when central nervous system infection provokes status.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom