PE24.4 | Status Epilepticus — Summary & Reflection

KEY TAKEAWAYS

Status epilepticus is defined operationally as a seizure ≥5 minutes or ≥2 seizures without recovery. The management algorithm is time-based: Phase 0 (0–5 min: ABCs, oxygen, blood glucose check); Phase 1 (5–10 min: lorazepam 0.1 mg/kg IV/IO or midazolam 0.2–0.3 mg/kg buccal/IM if no IV access); Phase 2 (10–30 min: phenytoin 18–20 mg/kg IV in saline at ≤1 mg/kg/min, OR levetiracetam 40–60 mg/kg IV — ConSEPT/EcLiPSE trials support levetiracetam as non-inferior to phenytoin; phenobarbitone 15–20 mg/kg IV is preferred in neonates); Phase 3 (>30 min: refractory SE — RSI, anaesthetic infusion, PICU). Always correct metabolic causes simultaneously. GABA-A receptor internalisation explains why benzodiazepine efficacy declines with duration — treat early. In TB-endemic regions, suspect isoniazid toxicity in refractory SE; antidote is pyridoxine 70 mg/kg IV.

REFLECT

A child presented to the ward with a 10-minute generalised seizure and was given rectal diazepam by the nurse before a doctor arrived — the seizure stopped. Reflect on this scenario: was the nurse's action appropriate? What should the next clinical steps have been? Were there metabolic causes that should have been checked? Now consider: if the same child had arrived with an active seizure and IV access was already in place, could you recall the lorazepam dose in mg/kg and calculate the volume to draw up from memory? What would you need to practise before you feel confident managing SE alone as an intern?