1.Definition and Classification
T1 (time to treat): 5 min convulsive — treat. T2 (time to damage): 30 min — must be controlled. Non-convulsive SE (NCSE). Refractory. Super-refractory.
2.Phase I: Initial Therapy (0–10 min)
Benzodiazepines first. Do not delay for EEG. ABCs. Check glucose — Thiamine 100 mg + D50 if <60 mg/dL.[+]
Preferred Agents (Choose One)
Lorazepam: 4 mg IV (0.1 mg/kg). May repeat once.[+]
Midazolam IM: 10 mg (>40 kg) or 5 mg (<40 kg). First line pre-hospital or no IV.[+]
Diazepam: 10 mg IV (0.15 mg/kg).[+]
3.Phase II: Urgent Control (10–30 min)
ESETT: Levetiracetam, Fosphenytoin, and Valproate equally effective (~50% cessation). Start if seizure continues after Phase I.[+]
Agents (Choose One)
Levetiracetam: 60 mg/kg IV (max 4500 mg), over 15 min.[+]
Fosphenytoin: 20 mg PE/kg (max 1500 mg PE). Up to 150 mg PE/min. Cardiac monitoring.[+]
Valproic Acid: 40 mg/kg IV (max 3000 mg), over 10 min. Avoid in liver disease, pregnancy.[+]
Phenobarbital: 15 mg/kg IV. Risk of hypotension, respiratory depression.[+]
4.Phase III: Refractory (30–60 min)
Anesthetic infusion. Intubation usually required. Continuous EEG to titrate.[+]
Continuous Infusions
Midazolam: load 0.2 mg/kg, then 0.1–2 mg/kg/h. Propofol: load 1–2 mg/kg, 20–200 mcg/kg/min (watch PRIS). Ketamine: load 1.5–4.5 mg/kg, 1–10 mg/kg/h (hemodynamically stable, NMDA). Pentobarbital: load 5–15 mg/kg, 0.5–5 mg/kg/h (hypotension common).
5.Phase IV: Super-Refractory (>24 h)
Ketamine. If NORSE: empiric steroids (e.g. methylprednisolone 1 g × 3–5 d) or IVIG. Ketogenic diet, hypothermia, VNS — mixed evidence.[+]
6.Diagnostic Workup
Stat: glucose, lytes, AED levels, tox. CT then MRI. LP if febrile or immunocompromised. Rule out: stroke, infection, metabolic, withdrawal, autoimmune encephalitis.[+]
Do not delay Phase I or II for workup. Treat first, then diagnose.