Status Epilepticus
Neurology
Illness script · Neurology
Status Epilepticus
Seizure lasting ≥5 minutes OR ≥2 seizures without return to baseline consciousness between them.
This illness script for Status Epilepticus covers predisposing factors, classic presentation, mechanism, workup, management, and the clinical pivots that separate it from look-alikes—written for USMLE Step 1 and clerkship reasoning.
01
Predisposing factors
- AED non-compliance is the #1 cause in known epileptics
- Acute symptomatic: stroke, TBI, CNS infection, metabolic derangement
- Alcohol withdrawal or toxin ingestion
- Hyponatremia, hypoglycemia, hypocalcemia
- Fever/CNS infection in children (febrile SE)
- Prior history of epilepsy
02
Presentation
- Convulsive SE: tonic-clonic activity >5 min with impaired consciousness
- Non-convulsive SE (NCSE): altered mental status without obvious motor activity — requires EEG
- May see eye deviation, subtle rhythmic limb jerking in NCSE
- Post-ictal state should resolve; persistent AMS flags NCSE
- Autonomic instability: tachycardia, hypertension, hyperthermia
03
Pathophysiology
- Failure of seizure termination due to GABA-receptor internalization and NMDA-receptor upregulation
- Excitotoxic neuronal injury begins within minutes of sustained seizure activity
- Systemic consequences: hyperthermia, lactic acidosis, rhabdomyolysis, hypoxia
- Refractory SE: GABA agonists become less effective over time — escalation required
04
Diagnostics
- Fingerstick glucose immediately — rule out hypoglycemia
- Labs: BMP, CBC, AED levels, tox screen, LFTs, ammonia
- CT head after stabilization to rule out structural cause
- LP if CNS infection suspected (after CT)
- EEG — gold standard for NCSE diagnosis; continuous EEG in refractory cases
- MRI superior for structural etiology once stabilized
05
Management
- 0–5 min: ABCs, IV access, glucose (thiamine first if alcoholic), O2
- 5–20 min (benzodiazepine phase): IV lorazepam 0.1 mg/kg (preferred) OR IM midazolam 10 mg
- 20–40 min (second-line): IV fosphenytoin, valproate, or levetiracetam
- 40+ min (refractory SE): intubation + IV midazolam/propofol/pentobarbital infusion
- Treat underlying cause simultaneously (antibiotics for meningitis, correct electrolytes)
- Avoid phenytoin in alcohol withdrawal SE — valproate or levetiracetam preferred
06
Clinical pivots
How to separate this script from the look-alikes that show up on exams and on the wards.
Psychogenic Non-Epileptic Seizure (PNES)
Eyes closed during event, normal EEG during episode, no post-ictal confusion
Non-Convulsive Status Epilepticus
AMS without motor activity — EEG required to confirm; can only be distinguished by EEG
Syncope with convulsive movements
Brief (<30 sec) jerking, quick return to baseline, provoked by orthostatic trigger
Acute encephalopathy (metabolic/toxic)
Fluctuating AMS without ictal EEG correlate; seizure-like movements absent on EEG
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Educational use only. This illness script is a study framework, not medical advice. Confirm decisions with current guidelines and your clinical supervisors.