epilepticus

Status epilepticus (SE) is a neurologic emergency defined by prolonged seizure activity or repeated seizures without full recovery between them. Most guidelines define SE as a seizure lasting longer than five minutes, or two or more seizures without full recovery between them. The term has historical use, but status epilepticus remains the standard terminology.

SE is categorized as convulsive status epilepticus (CSE) and nonconvulsive status epilepticus (NCSE). CSE presents with continuous convulsions and impaired consciousness; NCSE features altered consciousness with minimal or no motor signs and often requires electroencephalography (EEG) for diagnosis.

Causes include acute brain injury such as stroke or head trauma, CNS infections, brain tumors, metabolic disturbances (hypoglycemia, hyponatremia, hypoxia), withdrawal from alcohol or sedatives, and drug nonadherence or intoxication.

Prolonged abnormal neuronal activity leads to metabolic stress and potential neuronal injury. Without timely control, SE can progress to refractory SE, which requires more intensive therapy and often ICU care.

Diagnosis relies on clinical assessment and EEG to detect NCSE and guide treatment; laboratory tests and imaging help identify underlying causes. Emergency management follows ABC priorities: protect the airway, ensure breathing, and maintain circulation. First-line treatment is a benzodiazepine (for example, lorazepam IV, or diazepam IV/rectal, or midazolam IM). If seizures persist, second-line antiseizure drugs such as phenytoin/fosphenytoin, valproate, or levetiracetam are used. Refractory SE may require anesthetic infusion (propofol, midazolam, or thiopental) in the ICU, alongside treatment of the underlying cause. Definitions: refractory SE persists after two appropriate medications; superrefractory SE continues despite anesthesia for 24 hours or more.

Outcomes vary by etiology and duration; prognosis worsens with brain injury, older age, or delayed treatment. SE is a common emergency in both adults and children, and rapid, guideline-based management improves survival and reduces complications.