Convulsive status epilepticus in adults
Convulsive seizure lasting 5 min or more, or repeated seizures without recovery between them. Children: use the paediatric pathway. Neonates: not covered.
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Emergency MedicineEmergency
Convulsive Status Epilepticus in Adults (AES 2016)
Convulsive Status Epilepticus in Adults (AES 2016): Convulsive status epilepticus in adults → Stabilise (0-5 min): airway, oxygen, monitoring, glucose →...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Action Stabilise (0-5 min): airway, oxygen, monitoring, glucose
Note the time the seizure started. Do not delay the benzodiazepine for tests.
- Airway, oxygen by mask, recovery position, suction. Intubate if breathing is not adequate.
- Monitor ECG, SpO2, BP and temperature.
- IV access (IO if IV fails). Take blood for glucose, electrolytes, FBC, toxicology and antiseizure drug levels.
- BGL below 4 mmol/L: thiamine 100 mg IV, then glucose 50% 50 mL IV (adult).
03Warning Pregnant 20 weeks or more, or up to 6 weeks after birth? Treat as eclampsia
Magnesium sulfate is the first-line anticonvulsant in eclampsia. Call obstetrics and anaesthetics now. Prepare magnesium per the local obstetric protocol (high-alert medicine). Renal impairment or low urine output: risk of magnesium toxicity; check serum magnesium. Myasthenia gravis: magnesium can cause respiratory failure; get specialist advice.
- Magnesium sulfate 4 g IV over 15 min, then 1 g/h IV for 24 h after the last seizure. Seizure again: further 2-4 g IV over 5-15 min.
- Seizure still going: also give a benzodiazepine (next step). Do not use valproate.
- BP 160/110 mmHg or more: treat urgently. On magnesium, watch reflexes, breathing and urine output.
04Action Benzodiazepine now (5-20 min): one full dose
Adult doses (children: paediatric pathway; neonates: neonatal guideline). Give one full dose, not small split doses. Maximum 2 doses in total, including doses before hospital.
- No IV access: midazolam IM 10 mg if over 40 kg (5 mg/mL: 2 mL); 5 mg if 13-40 kg (1 mL).
- IV access: diazepam 0.15-0.2 mg/kg IV (max 10 mg per dose). May repeat once at 5-10 min.
- Or lorazepam 0.1 mg/kg IV (max 4 mg per dose). May repeat once at 5-10 min.
- Or midazolam 0.2 mg/kg buccal or intranasal (max 10 mg).
- Watch breathing; have bag-mask ventilation ready. Prepare the second-line drug now.
05Action At the same time: find and treat the cause
Do not delay anticonvulsants for tests or imaging.
- Suspected CNS infection: start IV antibiotics and aciclovir now. No lumbar puncture while seizures continue.
- Check Na, Ca, Mg, glucose, renal and liver function, blood gas, CK, drug levels and toxicology. Pregnancy test in women who could be pregnant.
- Treat specific causes: severe hyponatraemia, hypocalcaemia, alcohol withdrawal, isoniazid overdose (pyridoxine).
- Tricyclic or other sodium-channel-blocker overdose: sodium bicarbonate; avoid phenytoin. Poisons Information 13 11 26.
- Missed antiseizure medicine is a common cause: restart the usual drugs.
- CT head when stable. Consider MRI and EEG.
- Dissociative (non-epileptic) seizures can look like status epilepticus. If in doubt, treat as status epilepticus.
06Decision Seizure stopped after the benzodiazepine?
Reassess 5-10 min after each dose. Still seizing after the first dose (including IM or buccal midazolam): give one more benzodiazepine dose, IV if access. Still seizing after 2 doses: go to second-line.
- If Yes
07Outcome Seizure stopped: observe and treat the cause
Not back to baseline, or subtle twitching: suspect non-convulsive status and get an urgent EEG. Restart usual antiseizure medicine.
If No08Action Second-line (20-40 min): ONE IV drug, full dose
Continuous ECG and BP monitoring. Start as soon as 2 benzodiazepine doses have failed.
- Levetiracetam 60 mg/kg IV (max 4500 mg) over 10 min. Quick to give; few adverse effects.
- Or phenytoin 20 mg/kg IV (max 1500 mg) at max 50 mg/min (25 mg/min if elderly or heart disease). Give undiluted into a large vein; flush with 0.9% sodium chloride; do not mix with glucose. Not in bradycardia, SA or AV block, or tricyclic overdose. Already on phenytoin: choose another drug.
- Or fosphenytoin 20 mg PE/kg IV (max 1500 mg PE) at max 150 mg PE/min, where available (not on the ARTG). Same cautions as phenytoin.
- Or valproate 40 mg/kg IV (max 3000 mg) over 10 min. Not in pregnancy, liver disease, POLG mitochondrial or urea-cycle disorder, or with a carbapenem. Women who could become pregnant: prefer levetiracetam.
- None of these available: phenobarbital 15 mg/kg IV (adult; total max 2 g), diluted 1 in 10, at max 60 mg/min. Not in porphyria. Expect hypotension and apnoea.
09Decision Seizure stopped after the second-line drug?
Reassess at the end of the infusion. With expert advice, a different second-line drug can be tried while ICU is on the way.
- If Yes
10Action Seizure stopped: admit, monitor, start maintenance
Not back to baseline: suspect non-convulsive status and get an EEG.
- Admit to a monitored bed; ICU if intubated or not waking.
- EEG if not back to baseline, or if intubated.
- Start maintenance antiseizure medicine; check drug levels where useful.
- Treat the cause. Agree an emergency management plan before discharge.
11Outcome Status epilepticus controlled
Continue maintenance antiseizure medicine and treatment of the cause.
If No12Warning Refractory status epilepticus: call ICU and anaesthetics now
Seizures continue after a benzodiazepine and a second-line drug.
- Intubate and ventilate for an anaesthetic infusion; start continuous EEG. Neuromuscular blockers hide convulsions: use a short-acting agent; then only EEG shows seizures.
- Expect hypotension: give fluids and a vasopressor as needed.
- Continue maintenance antiseizure medicine at full dose.
13Action Third-line (from 40 min): anaesthetic infusion with continuous EEG
Adult doses, in ICU. Titrate to stop seizures on EEG or to burst suppression.
- Midazolam 0.2 mg/kg IV bolus (intubated adult), then 0.05-2 mg/kg/h infusion.
- Or propofol 1-2 mg/kg IV bolus, then 30-200 microgram/kg/min. Above 4 mg/kg/h or beyond 48 h: risk of propofol infusion syndrome; check lactate, CK, K+ and triglycerides.
- Or thiopental (thiopentone) or pentobarbital: dose per ICU protocol. Pentobarbital is not on the ARTG.
- Keep seizure-free for 24-48 h, then wean slowly under EEG.
14Decision Seizures controlled on EEG?
Assess on continuous EEG, including during weaning.
- If Yes
15Outcome Controlled: wean after 24-48 h seizure-free
Wean the anaesthetic slowly under EEG. Continue maintenance antiseizure medicine and treat the cause.
If No16Warning Super-refractory: seizures 24 h or more after starting anaesthesia
Includes seizures that return on weaning. Get tertiary epilepsy and ICU advice.
- Look again for the cause, including autoimmune or infective encephalitis; consider immunotherapy with neurology.
- Specialist options include ketamine, another anaesthetic agent or a ketogenic diet.
- On propofol: check for propofol infusion syndrome.
17Outcome Tertiary specialist care
High risk of death and disability. Discuss goals of care with the family.
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
- Adult doses only. Children: use the paediatric status epilepticus pathway. Neonates are outside the AES 2016 guideline.
- Australia: fosphenytoin and pentobarbital are not on the ARTG; use phenytoin and thiopental. Midazolam injection is 5 mg/mL or 1 mg/mL.
- Non-convulsive status epilepticus needs EEG to diagnose and is not covered in detail.
- Third-line anaesthetic doses are specialist ICU doses; follow the local ICU protocol.
- Evidence for second-line and third-line choices is limited (AES Level U/B); ESETT found levetiracetam, fosphenytoin and valproate similar.
Contraindicated Populations
neonateschildren (use the paediatric status epilepticus pathway)
Applicable Regions
AUUSEUInternational
AU: Fosphenytoin and pentobarbital are not on the ARTG (special access only); use phenytoin 20 mg/kg and thiopental. Lorazepam 2 mg/mL and 4 mg/mL injections are on the ARTG. Midazolam injection is 5 mg/mL or 1 mg/mL.
UK: NICE NG217: IV lorazepam first in hospital (buccal midazolam in the community); levetiracetam, phenytoin or valproate second-line, levetiracetam may be quicker with fewer adverse effects.
US: Fosphenytoin and IV lorazepam are widely available; IM midazolam is common before hospital.
International: Phenobarbital may be the only option in resource-limited settings.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Convulsive Status Epilepticus in Adults (AES 2016)?
The Convulsive Status Epilepticus in Adults (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 Convulsive Status Epilepticus in Adults (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: 10.5698/1535-7597-16.1.48).
What are the limitations of the Convulsive Status Epilepticus in Adults (AES 2016)?
Known limitations include: Adult doses only. Children: use the paediatric status epilepticus pathway. Neonates are outside the AES 2016 guideline.; Australia: fosphenytoin and pentobarbital are not on the ARTG; use phenytoin and thiopental. Midazolam injection is 5 mg/mL or 1 mg/mL.; Non-convulsive status epilepticus needs EEG to diagnose and is not covered in detail.; Third-line anaesthetic doses are specialist ICU doses; follow the local ICU protocol.; Evidence for second-line and third-line choices is limited (AES Level U/B); ESETT found levetiracetam, fosphenytoin and valproate similar.. Individual patient factors may require deviation from these recommendations.
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