Clinical Commander

Back to dossier
neuro.status-epilepticus.core.v1PRODUCTION
neuro.status-epilepticus.core.v1

Convulsive Status Epilepticus

neurologyacuteadultpediatric
Hard-required inputs
0 / 12
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Convulsive SE per ILAE 2015 classification — stage 1 (5–30 min) abortive, stage 2 (30 min+) refractory, stage 3 (24h+ on cIV) super-refractory (Rossetti Lancet Neurol 2011)

Inputs
0
Actions
0
Advance rule
Set
Advance when

SE confirmed and stage assigned per ILAE 2015 criteria

Patient inputs (16)

cEEG within 60 min if persistent AMS post-control; rule out NCSE (NCS 2012 cEEG recommendation)

Pediatric vs adult dosing of benzodiazepines + AEDs (per ILAE 2020)

Fever as provoking factor — CNS infection, sepsis (NCS 2012 workup recommendation)

Hypo/hypernatraemia provokes seizures; correction rate matters (NCS 2012 metabolic workup)

Hypocalcaemia provokes seizures; ionised preferred (NCS 2012 metabolic panel)

Hypomagnesaemia + eclampsia (give MgSO4) provoking factors (NCS 2012)

Structural cause (ICH, mass, abscess); precedes LP if focal/AMS (AES 2016 workup)

Sedative-induced hypotension during cIV anesthetic (NCS 2012 hemodynamic monitoring)

Hypoxia from prolonged seizure / aspiration / sedation (AES 2016 airway assessment)

Hypoglycaemia is reversible cause — give thiamine BEFORE glucose in alcoholics (AES 2016)

Weight-based benzo + AED loading per AES 2016 dosing tables

t1 (5 min) starts abortive Rx; t2 (30 min) marks neuronal injury risk (ILAE 2015 Trinka et al)

Phenytoin / valproate / phenobarbital / levetiracetam levels — albumin-correct phenytoin (NCS 2012 AED monitoring)

Free-phenytoin correction (Sheiner-Tozer equation) when hypoalbuminemic (NCS 2012)

Eclampsia → MgSO4 first-line; alters AED choice (ACOG 2020 eclampsia management)

INH overdose → pyridoxine; cocaine/sympathomimetic; alcohol withdrawal (AES 2016 toxin-provoked SE)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningstage_3_refractory
    Stage 3 (40+ min — refractory) — failed Stage 1 + Stage 2 (Rossetti Lancet Neurol 2011 refractory definition)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningstage_4_super_refractory
    Stage 4 (>24 h on cIV — super-refractory) — continued or recurrent SE >24 h on first cIV agent (Shorvon/Rossetti Lancet Neurol 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningeclampsia
    Pregnancy ≥20 weeks or ≤6 weeks postpartum with seizure (ACOG 2020 eclampsia criteria)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningautoimmune_norse_fires
    New-onset refractory SE (NORSE) or febrile-infection-related epilepsy syndrome (FIRES — pediatric NORSE variant; preceded by febrile illness 2 wk prior)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpris_suspicion
    Propofol Infusion Syndrome (PRIS) — any 2 of: lactic acidosis (lactate ≥2.5), CK ↑ (>5000), triglycerides ↑ (>500), bradycardia, hypotension on increasing pressors, RBBB/Brugada-pattern ECG; risk = propofol >80 µg/kg/min for >48 h (NCS 2012 PRIS criteria)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverestage_1_early
    Stage 1 (5–20 min — early/abortive) — continuous seizure ≥5 min OR recurrent without recovery (ILAE 2015 t1 operational definition)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverestage_2_established
    Stage 2 (20–40 min — established) — seizure not terminated after 2 benzo doses (AES 2016 escalation criteria)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinh_overdose_seizure
    Seizure with INH (isoniazid) overdose history; toxic-metabolic etiology (AES 2016 toxin-provoked SE)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepres_phenotype
    Posterior reversible encephalopathy syndrome (PRES) — typical occipital/parietal vasogenic edema on MRI; hypertensive emergency, eclampsia, immunosuppressants (cyclosporine, tacrolimus), uremia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatealcohol_withdrawal_seizure
    Seizure in alcoholic / malnourished patient — withdrawal-spectrum (AES 2016 provoked SE)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Status epilepticus — NCS/AES 4-stage ladder
axis: se_4_stage_ladderstep 1 - Stage 1 — Initial therapy (5–20 min) per AES 2016
Selected step "Stage 1 — Initial therapy (5–20 min) per AES 2016" — Continuous seizure ≥5 min OR recurrent without recovery (ILAE 2015)
  • lorazepam
    first line
    benzodiazepine
    0.1 mg/kg IV (typical 4 mg per dose; max 4 mg per dose); can repeat once at 5 min (AES 2016 Glauser et al) • IV • q5 min × 2 max (max: 4 mg per dose, 8 mg cumulative)
    triggers: IV_access_available
    AES 2016 + Treiman NEJM 1998 — first-line IV benzo; repeat once at 5 min
    rxcui 6470
  • midazolam
    first line
    benzodiazepine
    10 mg IM (or 5 mg if <40 kg); IN 0.2 mg/kg; buccal 0.5 mg/kg • IM/IN/buccal • single (max: 10 mg single dose)
    triggers: no_IV_access
    RAMPART (NEJM 2012) — IM midazolam non-inferior to IV lorazepam
    rxcui 6960
  • diazepam
    add on
    benzodiazepine
    0.15–0.2 mg/kg IV (typical 5–10 mg); rectal 0.2–0.5 mg/kg if no IV • IV/PR • q5 min × 2 max (max: 20 mg cumulative)
    triggers: lorazepam_unavailable
    AES 2016 alternative when lorazepam unavailable; Treiman NEJM 1998 comparator
    rxcui 3322

outpatient playbook — drug actions (5)

  1. 1. levetiracetam maintenance
    500–1500 mg PO BID (renal-adjusted CrCl <50) • PO • BID
    trigger: Post-SE on LEV maintenance
    ILAE + AAN — LEV preferred 1st-line maintenance; minimal drug interactions; WCBA-safe
  2. 2. lamotrigine
    Titrate 25 mg PO daily × 2 wk → 50 mg daily × 2 wk → up to 200 mg BID (slow titration for SJS prevention) • PO • BID
    trigger: WCBA + need add-on or alternative to LEV
    ILAE — lamotrigine preferred for WCBA; slow titration to avoid Stevens-Johnson
  3. 3. lacosamide
    100–200 mg PO BID • PO • BID
    trigger: Focal-onset epilepsy + adjunct
    AAN — lacosamide for focal-onset; minimal interactions
  4. 4. folic acid (WCBA)
    4–5 mg PO daily • PO • daily
    trigger: Female of childbearing age on AED
    ILAE + ACOG — pre-conception folic acid for neural-tube defect prevention
  5. 5. AED taper consideration
    Per shared decision after 2 yr seizure-free • PO • per protocol
    trigger: ≥2 yr seizure-free + AAN 2015 shared decision
    AAN 2015 — recurrence risk ~30% after 2-yr taper; shared decision driven by EEG, MRI, and patient preference

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Continuous seizure ≥5 min (ILAE 2015 t1 definition, Trinka et al); Recurrent seizures without recovery to baseline (ILAE 2015 operational definition); AMS with seizure history — suspect NCSE (NCS 2012 cEEG indication).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Convulsive Status Epilepticus** (neuro.status-epilepticus.core.v1).
Phenotype framing: Provoked vs unprovoked per ILAE 2015 classification; convulsive vs non-convulsive vs focal SE; PNES exclusion
Scope: Convulsive SE per ILAE 2015 classification — stage 1 (5–30 min) abortive, stage 2 (30 min+) refractory, stage 3 (24h+ on cIV) super-refractory (Rossetti Lancet Neurol 2011)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Status epilepticus — NCS/AES 4-stage ladder** — step "Stage 1 — Initial therapy (5–20 min) per AES 2016".
1. lorazepam 0.1 mg/kg IV (typical 4 mg per dose; max 4 mg per dose); can repeat once at 5 min (AES 2016 Glauser et al) IV q5 min × 2 max (benzodiazepine, first line) — AES 2016 + Treiman NEJM 1998 — first-line IV benzo; repeat once at 5 min
2. midazolam 10 mg IM (or 5 mg if <40 kg); IN 0.2 mg/kg; buccal 0.5 mg/kg IM/IN/buccal single (benzodiazepine, first line) — RAMPART (NEJM 2012) — IM midazolam non-inferior to IV lorazepam
3. diazepam 0.15–0.2 mg/kg IV (typical 5–10 mg); rectal 0.2–0.5 mg/kg if no IV IV/PR q5 min × 2 max (benzodiazepine, add on) — AES 2016 alternative when lorazepam unavailable; Treiman NEJM 1998 comparator

Setting playbook (outpatient) — Long-term AED maintenance + driving restriction per state law + SUDEP risk discussion + women-of-childbearing-age counselling + AED-level monitoring + depression screening + trigger identification (AAN 2017 SUDEP + ILAE 2014 maintenance)
4. levetiracetam maintenance 500–1500 mg PO BID (renal-adjusted CrCl <50) PO BID — Post-SE on LEV maintenance (ILAE + AAN — LEV preferred 1st-line maintenance; minimal drug interactions; WCBA-safe)
5. lamotrigine Titrate 25 mg PO daily × 2 wk → 50 mg daily × 2 wk → up to 200 mg BID (slow titration for SJS prevention) PO BID — WCBA + need add-on or alternative to LEV (ILAE — lamotrigine preferred for WCBA; slow titration to avoid Stevens-Johnson)
6. lacosamide 100–200 mg PO BID PO BID — Focal-onset epilepsy + adjunct (AAN — lacosamide for focal-onset; minimal interactions)
7. folic acid (WCBA) 4–5 mg PO daily PO daily — Female of childbearing age on AED (ILAE + ACOG — pre-conception folic acid for neural-tube defect prevention)
8. AED taper consideration Per shared decision after 2 yr seizure-free PO per protocol — ≥2 yr seizure-free + AAN 2015 shared decision (AAN 2015 — recurrence risk ~30% after 2-yr taper; shared decision driven by EEG, MRI, and patient preference)

Non-pharmacologic actions:
- Epilepsy clinic follow-up at 1–2 wk post-discharge then q3 mo until seizure-free, then q6 mo
- Trigger identification + avoidance counselling (sleep, ETOH, fever, AED non-compliance)
- Medical alert bracelet ("epilepsy + AED list")
- Employment / vocational rehab counselling (driving + heights + machinery restrictions)
- Family/caregiver training in rescue benzo (rectal diazepam, intranasal midazolam, buccal midazolam)
- Mediterranean / low-glycemic diet counselling (epilepsy lifestyle)
- Aerobic exercise prescription (epilepsy is NOT a contraindication to exercise per ILAE)
- SUDEP discussion + nocturnal monitoring + seizure-detection device offered (AAN 2017 SUDEP)
- Vaccination per ACIP 2026

AVOID / contraindication checks:
- Valproate_avoid_in_pregnancy_and_mitochondrial (ESETT 2019 exclusion; ILAE 2015)
- Fosphenytoin_cardiac_monitoring_during_load (NCS 2012 safety)
- Propofol_PRIS_with_prolonged_or_high_dose (NCS 2012 PRIS criteria)
- Thiamine_before_glucose_in_alcoholics (AES 2016)
- Eclampsia_use_MgSO4_before_standard_ladder (ACOG 2020)
- INH_seizure_use_pyridoxine (AES 2016 toxin provoked SE)

Monitoring

Regimen monitoring:
- cEEG continuous until 24–48h seizure-free off cIV (NCS 2012 monitoring recommendation)
- BP continuous during cIV anesthetic (NCS 2012 hemodynamic monitoring)
- Serial AED levels with albumin correction for phenytoin (NCS 2012)
- Metabolic panel q4h initially (AES 2016 monitoring)
- ABG q1–2h during cIV (NCS 2012)
- Lipase or creatine kinase for PRIS surveillance (NCS 2012 propofol safety)

Setting (outpatient) monitoring:
- Clinic visit at 1–2 wk post-discharge for medication reconciliation + AED tolerability
- AED level at 4–6 wk after stable dose then q6 mo (or sooner if symptomatic)
- Seizure diary review at every visit
- PHQ-9 + GAD-7 at 90 d, 6 mo, then annually
- MoCA or cognitive screen if cognitive complaints
- BMP + LFT + CBC q6–12 mo (AED toxicity surveillance)
- DEXA q2 yr if on chronic enzyme-inducing AED

Follow-up plan: Long-term AED plan, driving counsel, epilepsy clinic referral per AAN/AES post-SE recommendations
- Close-out criterion: epilepsy clinic + driving + AED tapering plan set per AAN/AES guidelines

Monitoring phase: Continuous EEG until 24–48h seizure-free off cIV per NCS 2012; serial AED levels; vasopressor support during sedative wean

Disposition

Current setting: outpatient — Long-term AED maintenance + driving restriction per state law + SUDEP risk discussion + women-of-childbearing-age counselling + AED-level monitoring + depression screening + trigger identification (AAN 2017 SUDEP + ILAE 2014 maintenance)

Disposition criteria:
- Continue maintenance AED indefinitely (most epilepsy syndromes) OR taper after 2 yr seizure-free per shared decision (AAN 2015)
- Transition from neurology to primary care for stable patients (2 yr seizure-free) per regional model
- Surgical/device therapy if drug-resistant — VNS / RNS / DBS / resective surgery per epileptology eval

Escalation triggers (move to higher acuity):
- Breakthrough seizure → re-evaluate adherence + trigger + AED level; consider 2nd AED add-on (AAN 2015)
- Drug-resistant epilepsy (≥2 AED failed) → epileptology referral for surgical / VNS / RNS / DBS / dietary therapy (ILAE 2010 drug-resistant definition)
- SE recurrence → ED (NCS 2012)
- PHQ-9 ≥15 OR suicidal ideation → urgent psych referral (epilepsy + AED suicide-signal — FDA black-box on LEV / topiramate / VPA)
- Pregnancy declared → switch off VPA / topiramate; transition to LEV or lamotrigine BEFORE conception if possible; folic acid 4–5 mg PO daily

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Stage 3 (40+ min — refractory) — failed Stage 1 + Stage 2 (Rossetti Lancet Neurol 2011 refractory definition)
- [LIFE_THREATENING] Stage 4 (>24 h on cIV — super-refractory) — continued or recurrent SE >24 h on first cIV agent (Shorvon/Rossetti Lancet Neurol 2011)
- [LIFE_THREATENING] Pregnancy ≥20 weeks or ≤6 weeks postpartum with seizure (ACOG 2020 eclampsia criteria)

Citations

- NCS 2012/2016 SE Guideline (Brophy 2012) + AES 2016 Convulsive SE Guideline (Glauser 2016) + ILAE 2015 Classification (Trinka) + ILAE 2020 Pediatric SE + NICE NG217 (2024) + ESETT (Kapur NEJM 2019) + RAMPART (Silbergleit NEJM 2012) + ACOG 2020 Eclampsia. Guideline-floor WebSearch-revalidated 2026-05-18: Vignatelli Epilepsia 2024 systematic review of SE CPGs confirms NO paradigm change — midazolam/lorazepam first-line, LEV/fosphenytoin/valproate second-line all remain canonical. [PMID:31774955](https://pubmed.ncbi.nlm.nih.gov/31774955/)
- Cited evidence (PMID 22335736) [PMID:22335736](https://pubmed.ncbi.nlm.nih.gov/22335736/)
- Cited evidence (PMID 22528274) [PMID:22528274](https://pubmed.ncbi.nlm.nih.gov/22528274/)
- Cited evidence (PMID 26900382) [PMID:26900382](https://pubmed.ncbi.nlm.nih.gov/26900382/)
- Cited evidence (PMID 31005385) [PMID:31005385](https://pubmed.ncbi.nlm.nih.gov/31005385/)

Last reconciled with current guidelines: 2026-05-18.
References
  • NCS 2012/2016 SE Guideline (Brophy 2012) + AES 2016 Convulsive SE Guideline (Glauser 2016) + ILAE 2015 Classification (Trinka) + ILAE 2020 Pediatric SE + NICE NG217 (2024) + ESETT (Kapur NEJM 2019) + RAMPART (Silbergleit NEJM 2012) + ACOG 2020 Eclampsia. Guideline-floor WebSearch-revalidated 2026-05-18: Vignatelli Epilepsia 2024 systematic review of SE CPGs confirms NO paradigm change — midazolam/lorazepam first-line, LEV/fosphenytoin/valproate second-line all remain canonical. — PMID:31774955
  • Cited evidence (PMID 22335736) — PMID:22335736
  • Cited evidence (PMID 22528274) — PMID:22528274
  • Cited evidence (PMID 26900382) — PMID:26900382
  • Cited evidence (PMID 31005385) — PMID:31005385