Convulsive status epilepticus — staged emergency protocol

Diagnosis: established generalised convulsive status epilepticus (GCSE). Continuous seizure over 12 minutes — past the ILAE t1 threshold of 5 minutes, within the t1–t2 window where treatment is most likely to work.^[1][4]

Immediate assessment — ABCDE and time-critical first measures.^[2]

• Airway/Breathing — airway adjunct + recovery position, high-flow oxygen (target SpO2 94–98%); suction secretions. He is cyanosed and GCS 6 → prepare for intubation if not rapidly controlled.
• Circulation — IV access (obtained); send bloods including phenytoin level, U&E, LFT, calcium, magnesium, FBC, CRP, blood gas/lactate, toxicology, beta-hCG if relevant.
• Disability — glucose already checked and normal (6.4 mmol/L) — do not omit, hypoglycaemia is the classic mimic.
• Exposure — temperature 38.1°C (fever → consider CNS infection/sepsis); look for head trauma, infection source, neurocutaneous signs.

Stage 2 (5–20 min) — emergent IV benzodiazepine.^[2][4]

• Give IV lorazepam 4 mg (0.1 mg/kg) as a slow push; repeat once after 10 minutes if still seizing.
• If no IV access had been available, give IM midazolam 10 mg (RAMPART showed IM midazolam at least as effective and safe as IV lorazepam pre-hospital).^[3]

Stage 3 (20–40 min) — urgent control with a second-line antiseizure drug. He is still seizing after adequate benzodiazepine → established SE.^[2]

• Give IV levetiracetam 60 mg/kg (over 10–15 min), OR
• IV fosphenytoin 20 mg PE/kg (max 150 mg PE/min, with cardiac monitoring — risk of hypotension/arrhythmia), OR
• IV sodium valproate 40 mg/kg (max 10 mg/kg/min).
• The ESETT trial established these three agents are equally effective at aborting established SE (success ~half); levetiracetam is often preferred for ease (no cardiac monitoring, no interactions).^[2]

Stage 4 (over 40 min / refractory) — ICU and anaesthesia.^[4]

• If seizure continues: rapid-sequence intubation and transfer to ICU.
• Start an anaesthetic infusion — propofol OR midazolam OR thiopentone — titrated with continuous EEG to burst-suppression or seizure abolition for 24–48 h before slow weaning.
• Define refractory SE (ongoing despite benzodiazepine + one adequate second-line agent) and super-refractory SE (ongoing or recurring over 24 h of anaesthesia).

Treat the precipitant concurrently.^[4]

• Known epileptic on phenytoin with fever → check phenytoin level (non-adherence or sub-therapeutic is the commonest single cause); if CNS infection is suspected, give IV ceftriaxone + acyclovir and perform CT then LP once stable.
• Correct electrolytes; do not abruptly withdraw or switch his antiepileptic drugs.