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Status epilepticus

Key sources
The following summarized guidelines for the evaluation and management of status epilepticus are prepared by our editorial team based on guidelines from the World Health Organization (WHO 2023), the American Epilepsy Society (AES 2016), the The Scottish Intercollegiate Guidelines Network (SIGN 2015), the Neurocritical Care Society (NCS 2012), and the European Federation of Neurological Societies (EFNS 2010).
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Guidelines

1.Screening and diagnosis

Diagnostic criteria: define SE as ≥ 5 minutes of continuous clinical and/or electrographic seizure activity, or recurrent seizure activity without recovery between seizures.
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2.Classification and risk stratification

Classification
Classify SE as either:
convulsive SE: convulsions associated with rhythmic jerking of the extremities
non-convulsive SE: seizure activity seen on EEG without the clinical findings associated with convulsive SE
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Define refractory SE as SE not responding to the standard treatment regimens, such as an initial benzodiazepine followed by another antiepileptic drug.
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3.Diagnostic investigations

Initial evaluation
As per SIGN 2015 guidelines:
Obtain EEG to establish the diagnosis of SE and to monitor for treatment effect. Ensure that EEG is available as an emergency intervention in all patients with treated or suspected SE.
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Do not deter or delay treatment in patients with SE because of nonavailability of EEG.
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Obtain CBC, urea and electrolytes, liver function tests, calcium, glucose, clotting, measurement of antiepileptic drug levels, and store the collected blood for later tests. Measure blood gases to assess the extent of acidosis.
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4.Medical management

General principles: as per SIGN 2015 guidelines, establish the etiology of SE.
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More topics in this section

  • Initial management

  • Antiepileptic drugs (emergent therapy)

  • Antiepileptic drugs (urgent therapy)

  • Management of refractory SE

5.Inpatient care

Continuous EEG monitoring
As per SIGN 2015 guidelines:
Obtain EEG to differentiate between continued seizures and drug-induced sedation if the patient remains unresponsive after initial treatment.
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Obtain EEG to determine response to treatment in patients with seizures lasting > 30 minutes.
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6.Specific circumstances

Pediatric patients: as per WHO 2023 guidelines, consider administering IV fosphenytoin, phenytoin, levetiracetam, phenobarbital, or valproic acid (sodium valproate) with appropriate monitoring in pediatric patients with SE (seizures persisting after 2 doses of benzodiazepines).
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