There are many different presentations of status epilepticus. It can present with generalized bilateral involvement of skeletal muscles and loss of consciousness. It may begin as a focal seizure on one side, which then generalizes to the contralateral side, with loss of consciousness or, it may be nonconvulsive in nature. Status epilepticus can be confirmed by an electroencephalogram (EEG), but treatment should not be delayed pending an EEG result. The EEG can be used to confirm both clinically apparent and subclinical status epilepticus.

When a patient is experiencing a seizure, fundamental principles of advanced life support need to be applied. The patient should receive supplemental oxygen and should be intubated if the airway is compromised. Blood pressure, heart rate, and oxygen saturation need to be assessed. Intravenous (IV) access should be obtained and serum chemistry profiles, complete blood count, and serum glucose level assessed. If the glucose level is low, dextrose 50% (D50) should be administered. Glucose in the absence of thiamine should not be given unless hypoglycemia is documented since it can precipitate Wernicke encephalopathy in thiamine-deficient patients. Alternatively, patients can be given 100 mg of thiamine before or with glucose administration. Once IV access is obtained, intravenous benzodiazepines, preferably lorazepam (0.1 mg/kg) should be administered. It is important to note that administration of benzodiazepines may further compromise the patient’s mental and respiratory status. Therefore, preparation for intubation and mechanical ventilation should be done. If the seizure persists,
phenytoin 20 mg/kg should be given and repeat doses up to 30 mg/kg should be administered. The blood pressure, which may initially be elevated, can decrease with the administration of anticonvulsant therapy or after 15 to 30 minutes of continuous seizure activity due to impaired cerebrovascular autoregulation. Intravenous fluids and vasopressor support should be administered to maintain adequate blood pressure.