Introduction
Status Epilepticus (SE) is a true neurological emergency, defined as a prolonged seizure or recurrent seizures without recovery of consciousness in between. Prompt recognition and effective status epilepticus management UKMLA requires is vital, as ongoing seizure activity can lead to significant neuronal injury, systemic complications, and increased mortality. As a junior doctor, you will be expected to initiate the immediate management pathway confidently and escalate appropriately.
This guide provides a clear, 4-step framework based on current UK guidelines for managing convulsive status epilepticus in adults. We’ll cover the definition, common causes, the critical initial assessment and treatment algorithm, essential investigations, and post-SE care. This builds upon core neurological principles found in Neurology essentials for UKMLA: 7 high-yield syndromes and AKT diagnostic approaches.
Key Takeaways
Time is Brain: Status Epilepticus (SE) is a neurological emergency. Prompt recognition and rapid, protocol-driven treatment are crucial to prevent neuronal damage and mortality.
Definition Matters: Understand SE definitions (operational: continuous seizure >5 mins, or ≥2 seizures without recovery in between; established SE >30 mins).
ABCDE First: Secure airway, ensure adequate breathing/oxygenation, and establish IV access as immediate priorities alongside stopping the seizure. Check glucose immediately.
Benzodiazepines are First-Line: Administer adequate doses of benzodiazepines (e.g., IV Lorazepam, Buccal Midazolam) promptly as the initial treatment.
Escalate if Uncontrolled: If seizures persist after benzodiazepines, rapidly escalate to second-line (e.g., Levetiracetam, Phenytoin, Valproate) and then third-line (anaesthetic agents) treatments, involving senior help/critical care early.
Why Status Epilepticus Management UKMLA Demands Mastery
SE is a common neurological emergency with significant morbidity and mortality if not treated swiftly and correctly. Your ability to manage it is a core competency assessed in the UKMLA.
The AKT Context: Recognising SE and Choosing Correct Drug/Dose
The Applied Knowledge Test (AKT) will test your understanding of:
The definition of SE.
Common causes and triggers.
The step-wise pharmacological management, including correct drug choices, routes, and doses for first and second-line treatments.
Recognising potential complications. This involves skills in how you Master Interpreting Clinical Data.
The CPSA Context: Demonstrating the Emergency Algorithm
In the Clinical and Professional Skills Assessment (CPSA), you could face a simulation station requiring you to:
Perform a rapid ABCDE assessment on a seizing patient.
Correctly administer first-line benzodiazepines.
Recognise treatment failure and escalate appropriately (calling for senior help, initiating second-line therapy).
Communicate effectively with the team and potentially simulated relatives.
Demonstrate knowledge of the underlying principles found within Emergency Medicine Essentials for UKMLA.
Defining Status Epilepticus: More Than Just a Long Seizure
Understanding the definitions is crucial for knowing when to initiate emergency treatment.
Operational Definition (>5 minutes continuous / ≥2 without recovery)
For practical purposes, treatment for convulsive SE should be initiated for:
Any generalised convulsive seizure lasting longer than 5 minutes.
Two or more seizures occurring without recovery of consciousness between them.
Why 5 minutes? Most isolated seizures stop within 2-3 minutes. Seizures lasting longer than 5 minutes are less likely to stop spontaneously and require intervention.
Established SE (>30 minutes)
This refers to seizure activity persisting despite initial benzodiazepine treatment, typically beyond 30 minutes. Neuronal injury is thought to begin occurring around this point. Prompt escalation to second-line agents is vital.
Types (Convulsive vs. Non-Convulsive)
Convulsive SE: Characterised by repetitive generalised tonic-clonic movements. This is the most common and easily recognisable form, and the focus of this guide’s management algorithm.
Non-Convulsive SE (NCSE): Seizure activity without overt convulsions, presenting as altered consciousness, confusion, behavioural changes, or subtle motor signs. Diagnosis requires EEG. Management principles are similar but often less immediately urgent than convulsive SE.
Common Causes of Status Epilepticus
Identifying the underlying cause is important for long-term management, although immediate treatment shouldn’t be delayed.
Poor Medication Adherence: The most common cause in patients with known epilepsy.
Metabolic Disturbances: Hypoglycaemia (always check!), electrolyte imbalance (Na+, Ca++, Mg++), hypoxia, organ failure (uraemia, hepatic encephalopathy).
CNS Infections: Meningitis, encephalitis. Look for fever, neck stiffness, altered mental state.
Stroke / Haemorrhage: Acute stroke (ischaemic or haemorrhagic) can trigger SE.
Head Trauma: Can cause immediate or delayed seizures/SE.
Alcohol / Drug Issues: Acute intoxication or, more commonly, withdrawal (especially alcohol or benzodiazepines). Consider this alongside other common drug overdoses.
Brain Tumours: Primary or metastatic.
Hypoxia: Following cardiac arrest or respiratory failure.
Autoimmune Encephalitis.
Idiopathic: No clear cause found.
The 4 Urgent Steps in Managing Status Epilepticus
This step-wise approach is based on UK guidelines. Practical pathways, such as those used in NHS Scotland, outline the critical time points. Time is critical.
Step 1 (0-5 mins): Stabilise (ABCDE) & Initial Assessment
Action: Simultaneously manage immediate life threats while trying to gather information, following the ABCDE approach.
Airway: Position patient to avoid aspiration (recovery position if possible between seizures, careful positioning during seizure). Use basic airway manoeuvres (head-tilt/chin-lift/jaw thrust). Suction if needed. Consider nasopharyngeal airway if tolerated.
Breathing: Assess respiratory effort, rate, SpO2. Administer high-flow oxygen via non-rebreathe mask. Be prepared for bag-valve-mask ventilation if breathing becomes inadequate.
Circulation: Check pulse, BP. Establish secure IV access (ideally large bore). Send initial bloods (see Investigations). Monitor ECG.
Disability: Check bedside capillary blood glucose immediately. Treat hypoglycaemia urgently (e.g., IV 50ml 50% Dextrose). Assess pupils. Note seizure type/duration. If GCS is persistently low, consider airway protection needs (GCS ≤ 8 rule).
Exposure: Check temperature. Look for injuries sustained during seizure, signs of infection, or clues to cause.
History: If possible, obtain time of onset, previous epilepsy history, drug/alcohol use, recent illness from witnesses/records.
Step 2 (5-20 mins): First-Line Therapy (Benzodiazepines)
Action: Administer rapidly acting benzodiazepines to terminate seizure activity.
Preferred (with IV access): IV Lorazepam. Slower onset but longer duration of action than diazepam.
Alternative (no IV access): Buccal Midazolam. Absorbed well across mucous membranes. Rectal Diazepam is another option but less socially acceptable/practical.
Dosing: Ensure correct weight-appropriate doses are given (see Table 1). A second dose can be given if the seizure continues after 5-10 minutes.
Step 3 (20-40 mins): Second-Line Therapy (Non-Benzodiazepine AEDs)
Action: If seizures persist despite two doses of benzodiazepines (Established SE), call for senior help immediately (e.g., Medical Registrar, Anaesthetics/ITU) and start a second-line agent as per NICE Guideline NG217.
Options (IV Load):
Levetiracetam: Often favoured due to fewer interactions and side effects.
Phenytoin / Fosphenytoin: Effective but requires cardiac monitoring (risk of hypotension, arrhythmias). Avoid in certain seizure types. Needs slow infusion.
Sodium Valproate: Broad-spectrum, but potential teratogenicity and liver issues.
Choice: Often depends on patient factors (allergies, comorbidities, background AEDs) and local hospital guidelines. Ensure correct loading dose and infusion rate. Consider pharmacology principles regarding interactions and side effects.
Step 4 (>40 mins): Third-Line Therapy (Anaesthesia) / Refractory SE
Action: Seizures continuing despite adequate doses of first and second-line agents constitute Refractory Status Epilepticus. This requires urgent escalation to an Intensive Care Unit (ITU) setting.
Management: Requires general anaesthesia with agents like Propofol, Midazolam infusion, or Thiopental sodium, guided by anaesthetists/intensivists.
Monitoring: Continuous EEG monitoring is essential to confirm cessation of seizure activity (electrical and clinical).
Table 1: Status Epilepticus: First & Second Line Drug Dosing (Adults – Example Doses, Always Check Local/NICE Guidelines)
| Line | Drug | Route | Typical Adult Dose (Example) | Key Notes |
|---|---|---|---|---|
| First (5-20 min) | Lorazepam | IV | 4 mg | Preferred if IV access. Repeat once after 10-20 min if needed. |
| Midazolam | Buccal | 10 mg | No IV access. Repeat once after 10-15 min if needed. | |
| Diazepam | Rectal | 10-20 mg | Alternative if no IV/Buccal. | |
| Second (20-40 min) | Levetiracetam | IV Infusion | 60 mg/kg (max 4500 mg) over 15 min | Fewer interactions. Adjust dose in renal impairment. |
| Phenytoin / Fosphenytoin | IV Infusion | 20 mg/kg (Phenytoin Equivalents) at max rate 50 mg/min (Phenytoin) or 150 mg/min (Fosphenytoin) | Requires cardiac monitoring (BP, ECG). Many interactions. Use Fosphenytoin if available (less infusion site issues). | |
| Sodium Valproate | IV Infusion | 40 mg/kg (max 3000 mg) over 10-15 min | Broad spectrum. Monitor LFTs. Teratogenic. | |
| Third (>40 min) | Anaesthetic Agents (Propofol, Midazolam, Thiopental) | IV Infusion | ITU management | Requires intubation, ventilation, continuous EEG. |
(Doses are examples – ALWAYS refer to current NICE/SIGN/local guidelines and BNF/SmPC for precise dosing, infusion rates, and contraindications)
Essential Investigations in Status Epilepticus
While treatment shouldn’t be delayed, investigations run concurrently to identify the cause and potential complications.
Bedside: Glucose, VBG/ABG, ECG
Glucose: Already done – critical first step.
VBG/ABG: Check for hypoxia, hypercapnia (common post-seizure/due to respiratory depression), metabolic acidosis (lactate build-up from muscle activity), respiratory acidosis.
ECG: Check for arrhythmias, signs of ischaemia (seizures increase cardiac demand), features suggesting electrolyte disturbance (e.g., K+), or drug toxicity (e.g., prolonged QRS/QT in TCA overdose).
Bloods: FBC, U&Es, LFTs, Calcium, Magnesium, Glucose, CRP, AED Levels, Toxicology Screen
FBC: Leukocytosis (stress response or infection).
U&Es: Electrolyte disturbances (Na+, K+), renal failure (uraemia).
LFTs: Liver dysfunction, relevant for drug metabolism/toxicity.
Calcium, Magnesium: Low levels can trigger seizures.
CRP: Marker for infection/inflammation.
Anti-Epileptic Drug (AED) Levels: Crucial in known epileptics to check for sub-therapeutic levels due to non-adherence.
Toxicology Screen: If overdose or illicit drug use suspected. Consider specific levels (e.g., alcohol, salicylates).
Imaging: CT Head (often after initial stabilisation)
Indications: New onset SE, focal seizure onset, head trauma, persistent focal neurological deficit, suspicion of raised ICP or structural lesion (e.g., tumour, stroke, bleed).
Timing: Perform once the patient is stabilised (seizures controlled, airway secure if needed). Do not delay emergency treatment for imaging unless strong suspicion of rapidly expanding intracranial lesion requiring immediate neurosurgical intervention.
Further Tests: EEG, Lumbar Puncture (if infection suspected & safe)
EEG (Electroencephalogram): Essential for diagnosing non-convulsive SE and monitoring treatment effectiveness in refractory SE/anaesthesia.
Lumbar Puncture (LP): Indicated if CNS infection (meningitis/encephalitis) is suspected AND CT head shows no signs of raised ICP/mass lesion. Perform after starting antibiotics if bacterial meningitis is strongly suspected.
Table 2: Key Investigations in Status Epilepticus & Rationale
| Test | Timing | Primary Rationale |
|---|---|---|
| Capillary Glucose | Immediate (Step 1) | Rule out/treat hypoglycaemia (common reversible cause) |
| VBG/ABG | Early (Step 1/6) | Assess oxygenation, ventilation, acid-base status, lactate |
| ECG | Early (Step 1/6) | Check for arrhythmias, ischaemia, electrolyte/drug effects |
| Core Bloods (U&Es, Ca, Mg, FBC, LFTs, CRP, Coag) | Early (Step 1/6) | Identify metabolic triggers, infection markers, organ dysfunction |
| AED Levels / Toxicology | Early (Step 1/6 – if relevant) | Check adherence/toxicity in known epileptics; identify overdose |
| CT Head | After Stabilisation (usually) | Rule out structural cause (bleed, tumour, stroke) or raised ICP |
| EEG | If NCSE suspected / Refractory SE | Confirm seizure activity, guide anaesthetic therapy |
| Lumbar Puncture | If infection suspected & CT safe | Diagnose meningitis/encephalitis |
Post-Status Epilepticus Care
Once the seizure is terminated:
Identifying and Treating the Underlying Cause
This is crucial to prevent recurrence. Was it non-adherence? An infection? A stroke? Ensure appropriate investigations and treatments are commenced for the trigger.
Monitoring and Supportive Care
Patients often require close monitoring post-SE, potentially in a High Dependency Unit (HDU) or ITU, especially if second or third-line agents were used or if consciousness remains impaired. Monitor vital signs, neurological status, and watch for complications (e.g., aspiration pneumonia, rhabdomyolysis).
Medication Review and Optimisation
For patients with known epilepsy, review their regular AEDs. Ensure doses are optimal and address any adherence issues. For new onset SE, decisions about long-term AEDs will be made by neurology/specialists based on the underlying cause and risk of recurrence.
Putting It All Together: 2 UKMLA-Style Clinical Scenarios
Case 1: Known Epileptic Presenting in Convulsive SE
Vignette: A 25-year-old man with known epilepsy (usually well-controlled on Levetiracetam) is brought in by ambulance having a generalised tonic-clonic seizure for the last 8 minutes. Paramedics established IV access but gave no drugs.
Immediate Actions:
ABCDE: Ensure airway patent, high flow O2, confirm IV access working. Check bedside glucose (normal).
First-Line: Give IV Lorazepam 4mg. Note time.
Monitor: Continue ABCDE monitoring. Seizure stops after 2 minutes.
Post-Seizure: Position patient safely (recovery position). Obtain collateral history (missed doses?), send bloods (inc. Levetiracetam level). Observe closely.
Key Learning: Rapid first-line treatment as per algorithm. Importance of checking adherence/AED levels.
Concise Escalation Script (Failure of First Line)
“Senior help needed urgently in Resus Bay 1. 25-year-old male, known epilepsy, ongoing tonic-clonic seizure now >15 minutes total. Received IV Lorazepam 4mg five minutes ago with no effect. Proceeding to second dose Lorazepam and preparing Levetiracetam load. Requesting anaesthetic review for potential refractory status.”
Case 2: Elderly Patient with New Onset Focal SE (Stroke?)
Vignette: A 78-year-old woman with hypertension is brought in with acute confusion and repetitive twitching of her right arm and face, ongoing for 10 minutes. GCS 13 (E4 V4 M5), but not fully alert between twitches.
Immediate Actions:
ABCDE: Airway clear, O2 applied, IV access, bedside glucose normal.
First-Line: Give IV Lorazepam 4mg (even though focal initially, it’s prolonged and impairing consciousness). Twitching stops.
Investigate Cause: Clinical picture suspicious for new onset seizure secondary to stroke. Arrange urgent CT Head after stabilisation. Send routine bloods.
Monitor: Closely observe for further seizures or neurological deterioration. Involve neurology team.
Key Learning: Recognise prolonged focal seizures impairing consciousness as SE. Treat promptly. Prioritise investigating the underlying cause in new-onset seizures.
Frequently Asked Questions (FAQ) about Status Epilepticus Management
The absolute first step is SAFETY – ensure the patient is safe from injury (move harmful objects, cushion head if possible) and call for HELP. Simultaneously, note the TIME the seizure started or was first witnessed, as duration dictates management. Then immediately proceed to the ABCDE assessment, focusing on Airway and Breathing.
If a convulsive seizure doesn’t stop within 5-10 minutes after the first adequate dose of a benzodiazepine (e.g., IV Lorazepam 4mg), a second dose should be administered according to UK guidelines. If the seizure continues 5-10 minutes after the second dose, you should move to second-line agents and ensure senior/anaesthetic help is en route.
While both are effective benzodiazepines, IV Lorazepam generally has a longer duration of anti-seizure action in the brain compared to IV Diazepam (which redistributes more quickly out of the CNS). This may lead to more sustained seizure control after a single dose. However, if Lorazepam is unavailable, IV Diazepam is an acceptable alternative first-line agent.
IM Lorazepam or Diazepam are not recommended due to slow and erratic absorption. However, Buccal Midazolam is a recommended first-line option if IV access cannot be rapidly obtained, as it is absorbed reliably through the oral mucosa.
Phenytoin requires careful administration. Key risks include:
Hypotension and Bradycardia/Arrhythmias: Especially if infused too quickly. Requires continuous ECG and BP monitoring during infusion.
Infusion Site Reactions: Phenytoin solution is alkaline and can cause pain, inflammation, and even tissue necrosis if extravasation occurs (“purple glove syndrome”). Fosphenytoin (a pro-drug) is less irritant and generally preferred if available.
Drug Interactions: Phenytoin has numerous significant drug interactions.
NCSE is defined as continuous or rapidly recurring electrographic seizure activity without the overt tonic-clonic movements of convulsive SE. Patients present with altered consciousness, confusion, behavioural changes, or subtle motor signs (e.g., eye deviation, facial twitching). It requires a high index of suspicion and confirmation with EEG. While still an emergency needing treatment (often with similar agents to convulsive SE), the immediate management might focus less on respiratory compromise unless consciousness is severely impaired.
A blood gas (VBG or ABG) provides critical information quickly:
Acidosis: A significant metabolic (lactic) acidosis is common after prolonged convulsions due to muscle activity. Respiratory acidosis occurs if breathing is compromised.
Oxygenation/Ventilation: Assesses for hypoxia (PaO2) and hypercapnia (PaCO2) which can worsen outcome.
Electrolytes: Some analysers provide rapid potassium levels (hyperkalaemia can occur with muscle breakdown).
Lactate: Elevated lactate reflects tissue hypoperfusion or intense muscle activity.
Not always, but often. A CT head is generally indicated for new-onset status epilepticus to look for an underlying structural cause (stroke, bleed, tumour, trauma). It’s also needed if the patient has focal neurological signs, a persistently low GCS after seizure cessation, signs of head trauma, or suspicion of raised ICP. In patients with known epilepsy who return rapidly to baseline after SE caused by missed medication, imaging might be deferred, but this requires careful clinical judgement.
SUDEP stands for Sudden Unexpected Death in Epilepsy. While the exact mechanisms are complex and not fully understood, uncontrolled seizures, including status epilepticus, are a major risk factor for SUDEP. Effective management of SE and optimisation of long-term seizure control are crucial in reducing this risk.
The most current definitive UK guidance can be found within the NICE guideline NG217 (specifically Chapter 7). Scottish guidelines and practical pathways are also available, for example via NHS Scotland Right Decisions. Always refer to these and your local hospital trust guidelines.
Conclusion
Effective status epilepticus management UKMLA candidates must demonstrate hinges on rapid recognition, immediate application of the ABCDE approach, and timely, protocol-driven administration of anti-epileptic medications. Starting with benzodiazepines and escalating promptly to second and third-line agents if seizures persist is critical. Remember the importance of checking glucose immediately and investigating the underlying cause once the emergency is controlled.
Familiarity with the 4-step management pathway and practice through simulation are key to building competence and confidence in handling this neurological emergency. Your ability to act swiftly and systematically can significantly impact patient outcomes.
Your Next Steps
Memorise the Algorithm: Commit the 4-step management pathway (ABCDE/Glucose -> Benzos -> 2nd Line AEDs -> Anaesthesia/ITU) to memory. Know the key time points (5 mins, 20 mins, 40 mins).
Know First-Line Doses: Be certain of the correct doses and routes for IV Lorazepam and Buccal Midazolam in adults.
Learn Second-Line Options: Understand the main choices for second-line therapy (Levetiracetam, Phenytoin, Valproate) and their key considerations.
Practice ABCDE: Ensure your initial assessment of any acutely unwell patient is slick and systematic.
Review Causes: Use the AEIOU-TIPS mnemonic to remember common triggers for SE.
Practice Simulation: Utilise clinical skills labs or simulation training to practice managing an unconscious patient scenario, perhaps using resources like the Severn Deanery guide for structured approaches.
