Ongoing Seizure Activity
Convulsive seizure >5 min OR recurrent without recovery
All Pathways
Emergency MedicineEmergency
Status Epilepticus Management (AES 2016)
Status Epilepticus Management (AES 2016): Ongoing Seizure Activity → Stabilization Phase (T0) → First-Line: Benzodiazepine (0-5 min) → Seizure Stopped? ...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Stabilization Phase (T0)
ABCs, IV access, glucose check
- TIME IS CRITICAL - note exact seizure onset
- Position safely, protect airway
- Check fingerstick glucose - treat if <60 mg/dL
- Thiamine 100mg IV if suspected alcohol use/malnutrition
- Establish IV access (or IO if IV fails)
03Action First-Line: Benzodiazepine (0-5 min)
IMMEDIATE benzodiazepine administration
- IV LORAZEPAM: 0.1 mg/kg (max 4mg), may repeat once
- IV DIAZEPAM: 0.15 mg/kg (max 10mg), may repeat once
- IM MIDAZOLAM: 10mg if >40kg, 5mg if 13-40kg (no IV)
- INTRANASAL MIDAZOLAM: 0.2 mg/kg (max 10mg)
- RECTAL DIAZEPAM: 0.2-0.5 mg/kg (max 20mg)
04Decision Seizure Stopped? (at 5-10 min)
Reassess after first-line therapy
05Outcome Seizure Terminated
Continue monitoring, determine cause
06Action Second-Line Therapy (5-20 min)
Urgent control medication - choose ONE
- FOSPHENYTOIN: 20 mg PE/kg IV (max rate 150 mg PE/min)
- VALPROATE: 40 mg/kg IV (max rate 10 mg/kg/min, max 3000mg)
- LEVETIRACETAM: 60 mg/kg IV (max 4500mg) over 15 min
- PHENOBARBITAL: 15 mg/kg IV (if others unavailable)
- Prepare for intubation if no response
07Action Concurrent Workup
Do not delay treatment for workup
- Labs: BMP, Mg, Ca, CBC, AED levels
- CT head (after stabilization)
- LP if infection suspected
- Toxicology screen
- Consider MRI when stable
08Decision Seizure Stopped? (at 20-40 min)
Reassess after second-line therapy
09Action Post-SE Monitoring
ICU admission, EEG monitoring
- Continuous EEG if available
- Watch for non-convulsive SE
- Determine etiology (labs, imaging)
- Initiate maintenance AED therapy
10Outcome Controlled
Seizures terminated, begin maintenance therapy
11Warning REFRACTORY Status Epilepticus
Seizure continues after adequate 1st & 2nd line therapy
- Definition: SE persisting after adequate treatment
- Requires ICU admission
- Continuous IV anesthetics
- Intubation required
12Action Third-Line: Anesthetic Therapy
Continuous IV anesthetics with EEG monitoring
- MIDAZOLAM infusion: 0.2 mg/kg bolus, then 0.1-2 mg/kg/hr
- PROPOFOL: 1-2 mg/kg bolus, then 20-200 mcg/kg/min
- PENTOBARBITAL: 5-15 mg/kg, then 0.5-5 mg/kg/hr
- Target: EEG burst suppression or seizure cessation
- Maintain 24-48 hours, then slow wean with EEG
13Warning Super-Refractory SE
Continues ≥24h despite anesthetic therapy
- Ketamine infusion
- Immunotherapy if autoimmune suspected
- Hypothermia protocol consideration
- Epilepsy surgery consultation
- Ketogenic diet in select cases
14Outcome Poor Prognosis
Prolonged SE associated with high morbidity/mortality
- Path rejoins step 10Shared downstream outcome
Guideline Source
Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Time-based protocol - document seizure onset time carefully
- Benzodiazepine doses may need adjustment in elderly/hepatic impairment
- Second-line agent choice depends on availability and patient factors
- Refractory SE requires ICU and anesthesia involvement
- Non-convulsive status epilepticus requires EEG confirmation
Applicable Regions
USEUInternational
EU: Levetiracetam often first choice for second-line therapy
US: Midazolam IM increasingly used prehospital; IV lorazepam preferred in-hospital
International: Phenobarbital may be only option in resource-limited settings
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Status Epilepticus Management (AES 2016)?
The Status Epilepticus Management (AES 2016) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society.
What guideline is the Status Epilepticus Management (AES 2016) based on?
This algorithm is based on Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society (DOI: 10.1111/epi.13222).
What are the limitations of the Status Epilepticus Management (AES 2016)?
Known limitations include: Time-based protocol - document seizure onset time carefully; Benzodiazepine doses may need adjustment in elderly/hepatic impairment; Second-line agent choice depends on availability and patient factors; Refractory SE requires ICU and anesthesia involvement; Non-convulsive status epilepticus requires EEG confirmation. Individual patient factors may require deviation from these recommendations.
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