ICU Basics

Neuro

Status Epilepticus Algorithm

Benzodiazepine, second-line drug, then anesthesia

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 0–5 minutes: stabilize

  • Seizure lasting 5 minutes or more, or repeated seizures without recovery
  • Airway, oxygen, monitor, IV access; time the seizure
  • Fingerstick glucose: under 60 mg/dL, give thiamine 100 mg then dextrose

Still seizing → step 2

2 5–20 minutes: benzodiazepine

  • Lorazepam 0.1 mg/kg IV (max 4 mg), may repeat once
  • No IV: midazolam 10 mg IM (over 40 kg)
  • Or diazepam 0.15–0.2 mg/kg IV (max 10 mg)

Still seizing → step 3Stopped → step 4

3 20–40 minutes: second-line drug

  • Levetiracetam 60 mg/kg (max 4,500 mg), or
  • Fosphenytoin 20 mg PE/kg (max 1,500 mg PE), or
  • Valproate 40 mg/kg (max 3,000 mg)
  • The three worked equally well in ESETT; choose by comorbidity

Still seizing → step 5Stopped → step 4

4 After the seizure stops

  • Not waking within 10–20 minutes: EEG for nonconvulsive status
  • Look for the cause: glucose, sodium, calcium, magnesium, drugs, withdrawal, infection, stroke, tumor
  • CT head; LP if infection is possible

End of this path.

5 40+ minutes: refractory status

  • Intubate
  • Continuous midazolam, propofol or ketamine infusion
  • Continuous EEG to target seizure suppression
  • Neurology consult; search for the cause

End of this path.

Drugs in this algorithm

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