Status epilepticus !

Status epilepticus is a seizure that does not stop, or repeated seizures without recovery in between. It is an emergency that can damage the brain.

Updated 2026-11-01

Structures involved

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Why it happens

What it is

A seizure lasting 5 minutes or more, or two or more seizures without full recovery of consciousness between them. Convulsive status epilepticus is a time-critical emergency: the longer it lasts, the harder it is to stop and the greater the risk of brain injury and death.

Who gets it

Seen at any age, with peaks in young children and older adults. About half of cases occur in people without known epilepsy. In Colombia and Latin America, neurocysticercosis, central nervous system infections, head trauma and irregular access to antiseizure medicines are important causes; WHO notes a large epilepsy treatment gap in low- and middle-income countries.

Causes

In known epilepsy: stopping or missing antiseizure medicines, or low drug levels
Acute brain insults: stroke, head trauma, intracranial haemorrhage, tumour
Central nervous system infections: meningitis, encephalitis, neurocysticercosis
Metabolic causes: hypoglycaemia, hyponatraemia, hypocalcaemia, uraemia
Alcohol or sedative withdrawal, drug toxicity or overdose
Eclampsia in pregnancy or the postpartum period

Risk factors

Poorly controlled epilepsy or poor adherence to treatment
Previous status epilepticus
Young children with fever and older adults with stroke
Alcohol use disorder
Structural brain lesions

Pathophysiology

Normally seizures stop on their own because inhibitory GABA-mediated circuits regain control. In status epilepticus that fails: GABA-A receptors are pulled inside neurons and NMDA glutamate receptors increase, so benzodiazepines lose effect with time and excitation sustains itself. Prolonged firing causes excitotoxic neuronal death, especially in the hippocampus, plus systemic effects such as hypoxia, acidosis, hyperthermia and rhabdomyolysis.

Classification

Convulsive (generalised tonic-clonic) status epilepticus
Non-convulsive status epilepticus: altered consciousness with little or no movement, diagnosed by EEG
Focal status epilepticus with preserved or impaired awareness
Refractory status epilepticus: continues despite a benzodiazepine and one second-line drug
Super-refractory status epilepticus: persists 24 hours or more despite anaesthetic drugs

Symptoms and signs

Continuous tonic-clonic movements lasting 5 minutes or more
Repeated seizures without regaining consciousness between them
Unresponsiveness, eye deviation or subtle twitching of the face or limbs
Tongue biting, incontinence, cyanosis and noisy breathing
In non-convulsive status: confusion, staring or a coma that does not improve as expected

Diagnosis

Clinical: Diagnosed at the bedside from seizure duration and lack of recovery, while treatment starts. History from witnesses: known epilepsy, medicines, alcohol, trauma, fever, pregnancy. Check airway, breathing, circulation and capillary glucose at once.
Tests: Capillary and serum glucose, electrolytes including sodium, calcium and magnesium, kidney and liver function, blood count, arterial blood gas, creatine kinase, antiseizure drug levels and a toxicology screen; pregnancy test in women of childbearing age. Lumbar puncture when infection is suspected and imaging allows. EEG confirms non-convulsive status and guides treatment in refractory cases.
Imaging: Head CT once the patient is stabilised to look for bleeding, tumour, cysticerci or trauma; MRI later for structural causes.

Differential diagnosis

Psychogenic non-epileptic seizures
Convulsive syncope
Rigors from fever or sepsis
Movement disorders or drug-induced dystonia
Decerebrate or decorticate posturing from raised intracranial pressure
Metabolic or toxic encephalopathy without seizures

Goal of treatment

Stop the seizure as fast as possible, protect airway, breathing and circulation, correct reversible causes (especially hypoglycaemia) and prevent recurrence and brain injury.

Treatment

Acute: Stabilisation (0–5 minutes): lateral position, airway protection and oxygen, pulse oximetry and cardiac monitoring, intravenous access, capillary glucose, and thiamine before glucose when alcohol use or malnutrition is possible.
Acute: First line (about 5–20 minutes): a benzodiazepine, such as intravenous lorazepam or diazepam, or intramuscular midazolam when there is no intravenous access; intranasal or buccal midazolam and rectal diazepam are options outside hospital. It may be repeated once.
Acute: Second line (about 20–40 minutes) if seizures continue: an intravenous antiseizure drug such as fosphenytoin or phenytoin, valproate or levetiracetam; phenobarbital is an alternative. In eclampsia, magnesium sulfate is the drug of choice.
Acute: Refractory status: intensive care, intubation and continuous infusion of anaesthetic agents (midazolam, propofol or a barbiturate) guided by continuous EEG.
Follow-up: Nursing priorities: time the seizure, do not restrain the person or put anything in the mouth, pad the bed rails, suction and oxygen ready, watch respiratory depression after benzodiazepines, and record neurological checks and vital signs.

Drugs for this condition

Complications

Hypoxia, aspiration pneumonia and respiratory failure
Hyperthermia, lactic acidosis and rhabdomyolysis with acute kidney injury
Cardiac arrhythmias and neurogenic pulmonary oedema
Permanent neuronal injury, cognitive decline and later epilepsy
Death, especially in older adults and when caused by an acute brain insult

Prognosis

Depends mainly on the cause, the patient's age and how long seizures last. Status due to missed medicines in known epilepsy usually does well; status from anoxic injury, stroke or infection carries high mortality. Delays in starting a benzodiazepine make control harder.

Prevention

Regular use of prescribed antiseizure medicines and access to them
A written seizure rescue plan for people with epilepsy and their carers
Control and treatment of neurocysticercosis through hygiene and sanitation
Prenatal care to detect and treat preeclampsia

Test yourself

Think of the answer, then tap the question to see it.

What is the operational time threshold for treating a convulsive seizure as status epilepticus?

5 minutes of continuous seizure activity, or repeated seizures without recovery of consciousness in between.

Which drug class is first-line treatment for status epilepticus?

Benzodiazepines (for example lorazepam or diazepam intravenously, or midazolam intramuscularly).

Which bedside test should be done immediately in every seizing patient?

Capillary blood glucose, because hypoglycaemia is a quickly reversible cause.

Which second-line drugs are used when seizures continue after benzodiazepines?

Intravenous fosphenytoin or phenytoin, valproate or levetiracetam; phenobarbital is an alternative.

What is the drug of choice for seizures due to eclampsia?

Magnesium sulfate.

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Educational information, not medical advice. For any symptom, see a health professional.

Sources: Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society (Epilepsy Currents (American Epilepsy Society), 2016); Epilepsy: MedlinePlus Medical Encyclopedia (MedlinePlus, US National Library of Medicine, 2026); Epilepsy (World Health Organization, 2024).

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Representative model, for educational purposes only.

Temporal lobe highlighted on the Durgical 3D model