Status Epilepticus for the Hospitalist: Master the 5-Minute Crisis and Escalating Refractory Care

In this episode of Hospital Medicine Unplugged, we blitz status epilepticus (SE)—recognize at 5 minutes, give a full benzo dose fast, load a second-line ASD without delay, and escalate to ICU infusions + EEG when needed.

We open with the do-firsts (0–5 min): ABCs, oxygen, lateral positioning, monitors, IV/IO access, check glucose (give thiamine → dextrose if at risk), draw labs, consider tox screen, and don’t miss mimics. If persistent altered consciousness, order EEG early to uncover nonconvulsive SE.

Diagnosis & triage: SE = continuous seizure ≥5 min or recurrent seizures without recovery. Includes convulsive and nonconvulsive phenotypes; the latter is subtle—EEG is essential. Etiology buckets: structural (stroke/ICH/tumor/TBI), metabolic (electrolytes, organ failure), withdrawal/intoxication, medication non-adherence, autoimmune/NORSE, infection. Etiology predicts outcome—hunt it while you’re treating.

First-line (5–10 min): benzodiazepine—full dose, once, fast. • IV lorazepam 0.1 mg/kg (max 4 mg); or IV diazepam 0.15–0.2 mg/kg (max 10 mg). • No IV? IM midazolam 10 mg (or IN/buccal 0.2 mg/kg). Speed and adequate dosing beat agent choice. Repeat once if still seizing and move on.

Second-line (10–30 min): established SE—levetiracetam, fosphenytoin, or valproate. • Levetiracetam 60 mg/kg (max 4.5 g), fosphenytoin 20 mg PE/kg (max 1.5 g PE), or valproate 40 mg/kg (max 3 g)—similar efficacy, choose by comorbidity/contraindications. • Levetiracetam/valproate favored in cardiac disease; avoid valproate in pregnancy or severe hepatic disease. • Consider lacosamide if alternatives limited.

Refractory SE (30–60+ min): seizures persist after a benzo + one second-line ASD → ICU, intubate, start continuous EEG and anesthetic infusions: • Midazolam or propofol (titrate to seizure or burst suppression). • Watch for hypotension, infection, metabolic complications; protocolize weans to avoid withdrawal seizures.

Super-refractory (>24 h after anesthetics): broaden playbook—ketamine, additional ASDs, immunotherapy for suspected autoimmune/NORSE, ketogenic diet, neuromodulation (VNS/ECT), selective inhaled anesthetics, and surgical options for focal, resectable sources. Multidisciplinary team is non-negotiable.

EEG strategy that sticks: spot NCSE early; in refractory phases, continuous EEG guides infusion targets and catches breakthroughs. Diagnostic IV ASD trials under EEG can clarify ambiguous patterns.

Setting-specific pearls: • Alcohol withdrawal: benzodiazepines are primary; thiamine before glucose; phenytoin doesn’t treat withdrawal seizures. • Pregnancy: benzos for emergent control; levetiracetam or fosphenytoin next; avoid valproate when possible; magnesium for eclampsia. • Older adults: same ladder, but dose-low/go-slow, mind renal/hepatic function and drug–drug interactions.

Why the hurry? Prolonged seizures shift receptors (↓GABA, ↑NMDA), fuel neuronal injury and pharmacoresistance, and raise mortality (>20% in refractory cases). Early, protocol-driven care saves brain and life.

Medication pitfalls you don’t want to meet: under-dosing benzodiazepines, stacking sedatives without airway planning, ignoring QT/hypotension with fosphenytoin/propofol, and forgetting EEG in the quiet, confused patient.

We close with the SE bundle: (1) time-zero ABCs + glucose/thiamine; (2) full-dose benzo now; (3) immediate second-line load if still seizing; (4) early EEG (liberal for suspected NCSE); (5) ICU + continuous EEG + anesthetic infusion for refractory; (6) parallel etiology hunt (CT/MRI, labs, CSF/autoimmune as indicated); (7) structured wean and recurrence plan; (8) post-event counseling on adherence, triggers, and secondary prevention.

Fast benzo, full load, early EEG, decisive escalation—that’s how you beat status.