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This tool is educational and informational. It does not replace clinical judgment. Verify status epilepticus phase-locked treatment, weight-based dosing, and evidence-based medication selection against the cited source before acting.
Not prospectively validated. No clinical tool replaces bedside assessment.
This tool qualifies as non-device clinical decision support under the January 2026 FDA CDS guidance (21st Century Cures Act §3060). It does not acquire or analyze patient data, it displays the basis for its recommendations, it enables independent clinician review, and it is intended for use by trained healthcare professionals.
This runs entirely in your browser; we store nothing. Even so, enter only clinical data (age, vitals, exam findings) -- not names, MRNs, or other identifiers.
Tarvinder Singh, MD -- Vascular Neurologist. March 2026.
Status Epilepticus Protocol
Phase-based dosing and escalation for generalized convulsive status epilepticus.
Seizure Parameters
Elapsed seizure time
IV / IO access
Protect airway, establish access, check glucose -- do not give medications yet
- Position patient lateral (recovery position) to protect airway
- Supplemental O₂ -- target SpO₂ ≥94%
- IV or IO access -- attempt while calling for help
- Fingerstick glucose immediately (treat if <60 mg/dL: dextrose 50% 50 mL IV)
- Vital signs, continuous pulse oximetry, cardiac monitoring
- Note seizure onset time -- phase clock starts NOW
- Activate code stroke/neuro team if not already done
Benzodiazepine -- weight-based dose NOW. IM midazolam if no IV access.
- Give BZD dose immediately -- see dose calculator below
- If IV/IO access: lorazepam or diazepam IV (preferred)
- If NO IV/IO access: IM midazolam is first-line (RAMPART, PMID 22335736)
- Repeat once after 5 min if still seizing (same drug, same dose)
- Do NOT delay for IV access -- IM midazolam is equivalent or superior
- Prepare second-line agent now (order LEV/VPA/fosphenytoin) in case Phase 1 fails
Medications
0.1 mg/kg (range: 2--4 mg) | May repeat
Preferred IV BZD. Longer CNS half-life than diazepam. Avoid if hemodynamically unstable (causes vasodilation).
Trial: ACNS/AES 2016 Guidelines -- Level A. VA Cooperative Study (Treiman 1998, PMID 9738086): lorazepam 0.1 mg/kg superior to diazepam+phenytoin, PHB, and placebo. ACNS/AES 2016 Guidelines -- Level A. VA Cooperative Study (Treiman 1998, PMID 9738086)
0.15 mg/kg (range: --10 mg) | May repeat
Alternative to lorazepam when IV access available. Shorter CNS duration than lorazepam (redistribution). Follow with second-line agent sooner.
Trial: ACNS/AES 2016 Guidelines -- Level A ACNS/AES 2016 Guidelines -- Level A
0.2 mg/kg (range: --10 mg)
FIRST-LINE when no IV access. Intramuscular -- use anterolateral thigh or deltoid. Do NOT dilute. Single dose; establish IV access after administration.
Trial: RAMPART (Silbergleit 2012, PMID 22335736): IM midazolam 10 mg non-inferior to IV lorazepam 4 mg. Seizure cessation before hospital arrival: 73% vs 63% (p<0.001). Faster delivery, no venipuncture required. RAMPART (Silbergleit 2012, PMID 22335736)
Established SE -- give second-line antiseizure medication immediately
- BZD has failed (or max dose given) -- do NOT give additional BZD
- Choose second-line agent below (LEV/VPA/fosphenytoin -- equivalent per ESETT)
- IV access is mandatory for all Phase 2 agents
- Infuse over 10 min (LEV, VPA) or at ≤150 mg PE/min (fosphenytoin)
- Fosphenytoin: cardiac monitor and BP monitoring required during infusion
- Valproate: contraindicated in pregnancy, known liver disease, mitochondrial disease
- Notify ICU/intensivist -- refractory SE transition is imminent
- Order STAT continuous EEG (may need after intubation)
Medications
60 mg/kg (range: --4500 mg)
Preferred second-line agent. No hepatic metabolism, minimal interactions, no cardiac monitoring required. Common ED underdose: 1,000 mg -- correct dose is 60 mg/kg (max 4,500 mg).
Trial: ESETT (Kapur 2019, PMID 31774955): 47.4% seizure termination at 60 min. No difference vs VPA or fosphenytoin (all ~47%). Preferred first choice -- no cardiac monitoring or drug interaction concerns. ESETT (Kapur 2019, PMID 31774955)
40 mg/kg (range: --3000 mg)
Contraindicated in pregnancy (teratogenic), known liver disease, and mitochondrial disease. Check pregnancy status before use in women of childbearing age.
Trial: ESETT (Kapur 2019, PMID 31774955): 45.7% seizure termination at 60 min. Equivalent to LEV and fosphenytoin. ESETT (Kapur 2019, PMID 31774955)
20 mg PE/kg (range: --1500 mg PE)
Phenytoin prodrug. Rate constraint critical -- faster infusion causes cardiac arrhythmia and hypotension. Requires continuous cardiac monitoring. Dose in mg PE (phenytoin equivalents). Purple glove syndrome risk at IV site.
Trial: ESETT (Kapur 2019, PMID 31774955): 53.6% seizure termination at 60 min. Equivalent to LEV and VPA (not statistically superior). ESETT (Kapur 2019, PMID 31774955)
ICU transfer mandatory -- anesthetic coma with continuous EEG monitoring required
- TRANSFER TO ICU -- anesthetic agents require continuous monitoring
- STAT continuous EEG -- mandatory to guide titration of anesthetic agents
- Intubate if not already done (propofol/midazolam infusion requires intubation)
- Anesthetic options (titrate to burst-suppression on cEEG):
- • Midazolam infusion: 0.2 mg/kg IV load, then 0.1–0.4 mg/kg/h
- • Propofol infusion: 1–2 mg/kg IV load, then 2–8 mg/kg/h (watch PRIS at >48h)
- • Ketamine: 1.5 mg/kg IV load, then 1.2–5 mg/kg/h (NMDA antagonist, neuroprotective)
- • Phenobarbital: 20 mg/kg IV at ≤50–75 mg/min (alternative if above unavailable)
- Treat underlying cause -- metabolic, infectious, structural, autoimmune
- Propofol infusion syndrome (PRIS): monitor CK, triglycerides, pH if >48h or >4 mg/kg/h
Evidence Base
IM midazolam 10 mg vs IV lorazepam 4 mg for prehospital SE. Primary endpoint (seizure cessation without rescue Rx): 73.4% vs 63.4% (p<0.001). IM midazolam superior on primary outcome.
Levetiracetam vs fosphenytoin vs valproate for established SE. Seizure termination at 60 min: 47.4% vs 53.6% vs 45.7% (no significant difference). All three are acceptable second-line agents.
Neurocritical Care Society guidelines for evaluation and management of status epilepticus.
Level A: BZDs (lorazepam IV, IM midazolam, diazepam IV) are the preferred initial therapy for established SE. All equivalent when used at equivalent doses.