QuestionSBA
QuestionChoice
This would be a reasonable choice if the patient did not have IV access, but as we have secured access in this patient, IV lorazepam is a better option as it is faster acting and does not run the risk of whoever is administering it being accidentally bitten by the patient while they seize
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b
Give 10mg buccal midazolam
QuestionChoice
This is the next step if two doses of benzodiazepines do not work and the patient continues to be in status epilepticus. Be aware that phenytoin infusions are likely to cause a drop in blood pressure
32580
c
Start a phenytoin infusion
QuestionChoice
This patient may well need a neurology review and further investigations; however, the acute issue is their seizures, and the patient needs to be stabilised before referring to a specialty
32582
e
Refer to neurology
QuestionChoice
This patient is in status epilepticus, defined as a seizure lasting >5 minutes; or repeated seizures without regaining consciousness. Initial management is basic life support alongside benzodiazepines.
32578
a
Give a further intravenous (IV) 4mg lorazepam
QuestionChoice
Whilst airway protection is an important consideration and should be part of your initial and continuous assessment; we do not yet need to intubate in this instance. Other airway adjuncts may be better in the first instance, such as a nasopharyngeal airway
32581
d
Intubate the patient
QuestionComment
30 minutes is the old definition
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# Summary

Status Epilepticus is defined as a seizure lasting 5 minutes or more, or multiple seizures occurring within a 5-minute window without regaining full consciousness between episodes. It is a medical emergency, and treatment should begin promptly at the 5-minute mark. Initial management involves administering benzodiazepines, such as rectal diazepam, buccal midazolam, or intravenous lorazepam. If there is no response to two doses of benzodiazepines, second-line treatments include levetiracetam, phenytoin, or sodium valproate. Refractory cases may require general anesthesia with agents like propofol or midazolam. Investigations include blood tests, toxicology screen as well as neuroimaging and CSF analysis if the cause remains unclear

# Definition

Status epilepticus is defined as a seizure lasting 5 minutes or more OR multiple seizures over 5 minutes without returning to a full level of consciosuness between episodes.

It should be assumed at 5 minutes and appropriate treatment and investigations initiated.

# Acute management of status epilepticus

Emergency AED therapy for convulsive status epilepticus [NICE guidelines](https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures):




**Premonitory stage (0-10 minutes)** 

- Diazepam 10−20 mg given rectally, repeated once 15 minutes later if status continues to threaten, or midazolam 10 mg given buccally. If seizures continue, treat as below.

**Early status (0-30 minutes)** 

- If in the community:
	- Buccal Midazolam or Rectal Diazepam 
- If IV access is obtained and resuscitation facilities are available:
	- Lorazepam (intravenous) 0.1 mg/kg (usually a 4 mg bolus, repeated once after 10−20 minutes; rate not critical). 

**Established status (0-60 minutes)** 

- If not responding to 2 doses of benzodiazepine, give any of the following as second-line treatment
	- Levitiracetam
	- Phenytoin
	- Sodium Valproate

**Refractory status (30-90 minutes)**

- General anaesthesia, with one of:

	- Propofol (1–2 mg/kg bolus, then 2–10 mg/kg/hour) titrated to effect
	- Midazolam (0.1–0.2 mg/kg bolus, then 0.05–0.5 mg/kg/hour) titrated to effect
	- Thiopental sodium (3–5 mg/kg bolus, then 3–5 mg/kg/hour) titrated to effect; after 2–3 days infusion rate needs reduction as fat stores are saturated
	- Anaesthetic continued for 12−24 hours after the last clinical or electrographic seizure, then dose tapered.


# Investigations

- Arterial Blood Gas
- Routine Blood tests including FBC, U&E, LFT, CRP, Clotting, Bone Profile 
- Toxicology screen (urine)
- Anti-epileptic drug levels (if appropriate)
- If the underlying cause is unclear, further investigations can include:
	- CT/MRI Brain Imaging
	- Lumbar Puncture 


# References

[Click here for the NICE guidelines on managing status epilepticus](https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures)
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Status epilepticus requires immediate treatment with benzodiazepines, such as lorazepam.
A 24-year-old male is brought to the emergency department by ambulance after a witnessed generalised tonic-clonic seizure. He had initially appeared to recover but did not regain consciousness on his way to the hospital and has now started seizing again. Intravenous access is obtained, and he is given 4mg of lorazepam, but after 10 minutes, there is no response.

What is the next step in your management?
a