Stabilization adjuncts (0–5 min)
- • Thiamine 100 mg IV if alcohol use disorder or malnutrition suspected — give before glucose.
- • Pyridoxine 50–100 mg IV if isoniazid (INH) overdose or pediatric idiopathic SE suspected.
- • Pregnancy + active seizure: consider eclampsia → magnesium 4 g IV over 5–10 min, then 1 g/h (NOT benzo first). Benzodiazepine escalation is NOT first-line for eclamptic seizures (Mullhi 2025).
Convulsive SE only — NCSE route-out
Awaiting Step 1 ↑
Awaiting Step 2 ↑
Awaiting Step 3 ↑
Frequently asked questions
What is the first-line treatment for status epilepticus?
Benzodiazepines are first-line for all types of status epilepticus. Lorazepam 0.1 mg/kg IV (max 4 mg) is preferred; diazepam 0.15–0.2 mg/kg IV or IM midazolam 10 mg (>40 kg) are alternatives. Repeat once if seizure continues after 5 minutes.
What are second-line agents for status epilepticus?
Per the ESETT trial (NEJM 2019), levetiracetam 60 mg/kg IV (max 4500 mg), valproate 40 mg/kg IV (max 3000 mg), and fosphenytoin 20 mg PE/kg IV are equally effective second-line options with similar rates of seizure termination and adverse effects.
How is refractory status epilepticus managed?
Refractory SE (failed 2+ AEDs) requires ICU admission and continuous EEG monitoring. Anesthetic agents are used: propofol infusion, midazolam infusion, or ketamine infusion. Target burst-suppression or seizure termination on EEG. Treat underlying cause in parallel.