status epilepticus (SE) is a single seizure lasting > 5 minutes or a cluster of seizures lasting > 5 minutes without return of consciousness in between seizures

Monitoring & Evaluation:


  • Airway, breathing, SaO2, circulation, IV access
  • Neurologic exam

Brief History:

  • New onset vs. known epilepsy
  • Medication history (new, missed, or changed meds)
  • Substance abuse
  • Trauma

Evaluation (as clinically indicated):

  • Anti-seizure drug levels
  • Glucose POC, CMP, CBC, calcium, magnesium, phosphorous, NH3, hCG, toxicology screen
  • In patient’s with known seizures, no neuroimaging is warranted unless there is suspicion of trauma or other new CNS disease process
  • CT if concerned for trauma, intracranial hemorrhage
  • Otherwise, MRI is preferred
  • Fever? Consider:
    • Blood / urine cultures
    • lumbar puncture
    • Opening pressure
    • Culture
    • Cell counts
    • Protein
    • Glucose
    • HSV PCR
    • Antibiotics
      • Acyclovir


1st line:

  • Lorazepam 0.1 mg/kg IV or IO (max 4 mg), at 2 mg/min
  • OR, if no IV access: IM Midazolam 0.2 mg/kg (max 10mg)

2nd line (choose one):

  • Levetiracetam 60 mg/kg IV (max 4500 mg), infuse over 10 minutes
  • Fosphenytoin 20 PE/kg IV or IO (max 1500 mg), at 3 mg/kg/min (max rate 150) [Do no use in patients with known SCN1a/Dravet syndrome]
  • Valproic acid 40 mg/kg IV or IO (maximum 1000mg), infuse over 15 minutes [Only if patient is known to take valproic acid as a home medication]
  • PHENObarbital 20 mg/kg IV or IO, at 1 mg/kg/min (max 30)
    [For infants, strong consideration as initial 2nd-line therapy] [Prepare for intubation, especially in adolescents / adults]

3rd line (choose one):

  • Midazolam 0.15 mg/kg and start continuous infusion at 0.1 mg/kg/hr, increase by 0.1 mg/kg/hr until seizure resolution. Max dose: 2 mg/kg/hr 
  • PENTObarbital 5 mg/kg and start continuous infusion at 1 mg/kg/hr, increase by 0.5 mg/kg/hr until seizure resolution. Max dose: 5 mg/kg/hr

If seizures are controlled, maintenance therapy based on response:

  • Levetiracetam 60 mg/kg/day IV divided BID (max 1500mg BID)
  • Fosphenytoin 5 PE/kg/day IV divided BID
  • Phenobarbital 5 mg/kg/day IV divided BID (max 45mg BID)

Mitochondrial Cocktail: 

Should be started on any patient with cryptogenic/idiopathic status epilepticus that is not responsive to first anesthetic agent

  • Biotin 10 mg
  • Thiamine 100 mg daily
  • NAC (acetaminophen overdose protocol)
  • L-carnitine 1000 mg/day
  • Coenzyme-Q10 200 mg twice daily
  • Riboflavin 400 mg daily

EEG Electrode Basics

Left-sided electrodes = ODD
Right-sided electrodes = EVEN

Basic EEG Rhythms

beta (>13 Hz)
alpha (8-13 Hz)
theta (4-8 Hz)
delta (0.5-4 Hz)

Normal EEG

EEG waveform in a normal subject changes according to the level of consciousness.

EEG Waveforms and Age

Normal EEG Waveforms 

EEG Waveforms in Epilepsy

"spike and wave pattern"

EEG Waveforms in Epilepsy

"absence seizure"