🚑 EmergencyNeurology / EmergencyStudentInternResident

Seizures & Status Epilepticus

Also known as: convulsion · fits · status epilepticus · epilepsy emergency

A seizure lasting ≥5 minutes, or repeated seizures without recovery in between, is status epilepticus — a time-critical emergency. Stop the seizure quickly and find the cause.

Source · Reviewed 2026-08-15 · v1.0— AI-assisted draft — verify against the cited guideline before clinical use.

⚕️ Education only — not medical advice. Verify against the latest official guideline and your local protocol; confirm every drug dose against the cited source before clinical use.

Who gets it

People with known epilepsy (often missed medication), plus acute causes — hypoglycaemia, low sodium, CNS infection, stroke, head injury, eclampsia, alcohol/drug withdrawal and toxins.

Red flags — escalate / refer

Convulsion ≥5 minutes, or not regaining consciousness between seizures → treat as status epilepticus now.
Always check and correct glucose; consider eclampsia in pregnancy (magnesium is the treatment).
Airway compromise, hypoxia or ongoing seizures despite treatment → escalate to ICU.

Work-up / diagnosis

1ABC + high-flow oxygen + monitoring; check capillary glucose immediately and treat hypoglycaemia.
2Gain IV access; send glucose, electrolytes (Na, Ca, Mg), renal function, anti-seizure drug levels and toxicology.
3Look for the cause (infection, stroke, eclampsia, withdrawal); image/LP as indicated once stable.

Management — overview

0–5 min: protect the airway, give oxygen, position safely, correct glucose, and get IV access.
First-line (~5 min): a benzodiazepine — IV lorazepam (or IV diazepam; IM midazolam/buccal if no IV). May repeat once.
Second-line (still seizing): an IV anti-seizure medication — levetiracetam, (fos)phenytoin, or sodium valproate.
Refractory: rapid-sequence intubation and an anaesthetic infusion (midazolam/propofol) in ICU with EEG.
Eclampsia: give magnesium sulfate and expedite delivery/obstetric care. Treat the underlying cause throughout.

In-depthFull dosing & advanced protocol

Drug dosing

Benzodiazepine (first-line)

Stop the seizure (~5 min)

Adult dose: Lorazepam 0.1 mg/kg IV (usually 4 mg), repeat once after 5–10 min if needed (or diazepam 0.15–0.2 mg/kg IV; midazolam 10 mg IM/buccal if no IV)
Paediatric: Lorazepam 0.1 mg/kg IV; or buccal/IM midazolam 0.3 mg/kg
Route: IV / IM / buccal

Caution: Watch for respiratory depression; have airway support ready.

WHOWHO Model List of Essential Medicines (electronic EML) (2025 (24th)) ↗

Second-line anti-seizure medication

Ongoing seizure after benzodiazepine

Adult dose: Levetiracetam 60 mg/kg IV (max 4.5 g), OR phenytoin 20 mg/kg IV (≤50 mg/min, cardiac monitoring), OR valproate 40 mg/kg IV
Route: Intravenous

Caution: Phenytoin needs cardiac monitoring and must not be mixed with glucose; avoid valproate in pregnancy.

WHOWHO Model List of Essential Medicines (electronic EML) (2025 (24th)) ↗

Magnesium sulfate (eclampsia)

Seizure in pregnancy/eclampsia

Adult dose: IV/IM loading then maintenance per obstetric protocol
Route: Intravenous / intramuscular

WHOWHO recommendations on antenatal care for a positive pregnancy experience (2016) ↗

Timed algorithm & refractory status

Follow a timed protocol — delays worsen outcome; do not under-dose the benzodiazepine.
Refractory/super-refractory status needs ICU, continuous anaesthetic infusion and EEG monitoring.
Consider non-convulsive status (fluctuating consciousness) — it needs an EEG to diagnose.

ICMRStandard Treatment Workflows (STWs), India — Dept. of Health Research & ICMR (2022+) ↗

References

Guidelines change. If something here is out of date, tell us — we keep these current.

🚩 Report outdated / suggest update

More protocols

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👤 Who gets it

🚩 Red flags — escalate / refer

🔎 Work-up / diagnosis

🧭 Management — overview

💊 Drug dosing

Benzodiazepine (first-line)

Second-line anti-seizure medication

Magnesium sulfate (eclampsia)

📈 Timed algorithm & refractory status

📚 References

More protocols

👤 Who gets it

🚩 Red flags — escalate / refer

🔎 Work-up / diagnosis

🧭 Management — overview

💊 Drug dosing

Benzodiazepine (first-line)

Second-line anti-seizure medication

Magnesium sulfate (eclampsia)

📈 Timed algorithm & refractory status

📚 References

More protocols

Who gets it

Red flags — escalate / refer

Work-up / diagnosis

Management — overview

Drug dosing

Timed algorithm & refractory status

References

Who gets it

Red flags — escalate / refer

Work-up / diagnosis

Management — overview

Drug dosing

Timed algorithm & refractory status

References