Seizure & Status Epilepticus

Why this matters

Bystanders want you to stop the seizure. Putting an object in the mouth breaks teeth. Status epilepticus means the convulsion continues for about 5 minutes, or seizures recur without the patient recovering between them. It is an airway and brain emergency. First, protect the airway and check glucose. Do not call every leftover deficit just a seizure. Weakness after a seizure, called Todd paralysis, can look like a stroke. Low glucose can look like a seizure. Use the same sequence every time.

Clinical sequence

1. Protect the airway. Use a recovery position. Have suction ready. Do not pry the jaw. Check glucose.
2. If they are still convulsing past your protocol window, often about 5 minutes, give the benzodiazepine your protocol names. Use the intramuscular or intranasal route if there is no IV.
3. If this may be eclampsia, pregnant or up to 6 weeks postpartum, magnesium comes first. See eclampsia. Do not treat a possible eclamptic seizure with a benzodiazepine only.
4. After it stops, recheck the airway and glucose, take a temperature, and look for stroke and trauma. Todd paralysis is still a stroke workup until imaging.

What Counts as Status

• Convulsive status epilepticus uses about 5 minutes of convulsion as the teaching mark for when treatment should start. Seizures that repeat without recovery between them also count.
• If they are still seizing when you arrive, treat it as status epilepticus. Do not wait for a hospital EEG, or for a perfect clock, if they have been convulsing when you arrive.
• Intramuscular midazolam is an evidence-based route when there is no IV. Your protocol owns which benzodiazepine, which route, and the dose. This site does not publish milligrams.

During the Seizure

• Make the scene safe. Do not pin them face-down. Protect the head. Put nothing in the mouth.
• Time the event. Ask when it started. Ask for a clock time. “A few minutes” is not a time you can record.
• Position the airway and have suction ready. Give oxygen as indicated. Saturation looks terrible while they are not breathing. It often recovers when the convulsion stops.
• Check glucose as soon as you can do it safely.
• Give a benzodiazepine for ongoing or status seizures per protocol. See the benzodiazepine lesson. This page does not publish a dose.

After It Stops

• Use a recovery position if they are breathing and trauma care does not require something else.
• Reassess the airway, breathing, and circulation. Persistent hypoxia or gurgling means suction and airway care, not a long history.
• A one-sided deficit that does not clear is a stroke pathway in parallel. You already have the glucose. Get last known well, which is the last time they were seen normal.
• Say fever, neck stiffness, pregnancy, head trauma, and overdose on the radio when they are present. Do not refuse a first seizure in an adult and leave them to sleep unless your protocol or medical control allows it.

Common errors

• Do not use a bite stick, and do not hold them down so hard they cannot breathe.
• Do not skip the glucose check.
• Do not call status epilepticus “just a seizure” because it paused for five seconds.

Practice

Related: Benzodiazepines, Stroke.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• ILAE 2015 definition and classification of status epilepticus (convulsive t1 = 5 minutes; recurrent seizures without recovery)
• RAMPART (NEJM 2012) — IM midazolam is an evidence-based route when IV access is not available
• NASEMSO National Model EMS Clinical Guidelines (2022)
• Protect the airway, check glucose, and time the seizure. Treat status epilepticus with the benzodiazepine your protocol names. A one-sided deficit after the seizure still gets a stroke look.