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Status Epilepticus

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In one line

·A seizure that lasts more than 5 minutes is status epilepticus (a seizure that will not stop) — a brain emergency that can kill cells if it is not stopped fast.

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Normal physiology

·The brain has billions of nerve cells (neurons) that talk to each other using tiny electric signals. Two main chemicals keep the signals balanced: glutamate (which turns neurons on, like a gas pedal) and GABA (which quiets neurons down, like a brake pedal). Normally, these two stay in balance so brain activity stays smooth and controlled. A seizure that starts on its own usually stops within 1 to 2 minutes because the brain's GABA brakes kick in and shut the extra firing down.

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What goes wrong

·In status epilepticus (a seizure that will not stop), the seizure lasts longer than 5 minutes and the brain's GABA brakes start to fail, so the runaway firing does not stop on its own and becomes harder to stop even with medicine.

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Hallmark signs

·Shaking that won't stop for more than 5 minutes
·Multiple seizures one after another with no time to wake up in between
·Not waking up or responding after a seizure that seemed to stop
·Fast breathing or pauses in breathing
·Blue lips or fingertips
·Fever or high body temperature
·Confusion or strange behavior that lasts a long time
·Foaming or drooling from the mouth

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Red flags · escalate now

·Seizure lasting longer than 5 minutes without stopping
·Not breathing well or turning blue
·Not waking up between seizures or after the shaking stops
·First-ever seizure in someone who has never had one before
·Seizure in a pregnant woman, which could signal eclampsia (a dangerous pregnancy complication)

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Workup

·Fingerstick blood glucose (point-of-care glucose)
·Serum electrolytes (sodium, calcium, magnesium)
·Serum anti-epileptic drug (AED) levels (e.g. phenytoin, valproate, carbamazepine)
·Arterial or venous blood gas (ABG or VBG)
·Complete blood count (CBC) and metabolic panel (CMP) including creatinine and liver enzymes
·Toxicology screen (urine and serum) including alcohol level
·Head CT (computed tomography) without contrast, or brain MRI if time allows
·Electroencephalogram (EEG, brain wave test)

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Treatment

·Check fingerstick glucose immediately; if < 60 mg/dL, give 25 grams of IV dextrose (D50W, one amp) or 1 mg glucagon IM if no IV
·Establish IV access and give lorazepam 4 mg IV over 2 minutes (or diazepam 10 mg IV, or midazolam 10 mg IM if no IV) within the first 5 to 20 minutes
·Secure the airway, give high-flow oxygen, position the person on their side, suction secretions if needed, and prepare for intubation if they cannot protect their airway
·If seizure continues after benzos (refractory status epilepticus (a seizure that will not stop), after 20 minutes), give a second-line anti-seizure medicine: levetiracetam 60 mg/kg IV (max 4500 mg), OR fosphenytoin 20 mg PE/kg IV (max 1500 mg PE), OR valproate 40 mg/kg IV (max 3000 mg)
·If still seizing after 40 to 60 minutes (established refractory status epilepticus (a seizure that will not stop)), start continuous IV anesthetic: midazolam infusion (0.2 mg/kg bolus, then 0.1–2 mg/kg/hr), OR propofol (1–2 mg/kg bolus, then 20–200 mcg/kg/min), OR pentobarbital (5–15 mg/kg load, then 0.5–5 mg/kg/hr). Requires ICU, intubation, and continuous EEG monitoring.
·Cool the body with ice packs to groin, armpits, and neck; give cool IV saline; use a cooling blanket if temperature rises above 39°C (102.2°F)
·Identify and treat the underlying cause: restart or load anti-seizure medicine if levels are low, give thiamine 500 mg IV and treat alcohol withdrawal if the person drinks daily, start antibiotics and acyclovir if meningitis or encephalitis is suspected, reverse toxins or poisons, correct electrolytes, image the brain to find stroke or bleed

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NCLEX trap

·Any seizure that runs longer than 5 minutes IS status epilepticus (a seizure that will not stop) — a brain emergency, not a regular seizure that will end by itself. Start treatment immediately at the 5-minute mark. Do not wait and watch.
·Status epilepticus (a seizure that will not stop) follows a timed protocol: first benzodiazepine dose at 5 minutes, second dose at 10–15 minutes if still seizing, then a different seizure medicine (like fosphenytoin or levetiracetam) at 20–40 minutes. It is rapid, stepwise escalation on the clock — not 'try one thing and wait.'
·Status epilepticus (a seizure that will not stop) can look almost silent — just a flicker of the eyelid, a twitch in one finger, or no movement at all (nonconvulsive status). The brain's 'off switch' (inhibitory signals from GABA, the brain's main calming messenger) is broken in both the obvious and the quiet kinds. Watch the face, eyes, and small muscle movements closely.
·Status epilepticus (a seizure that will not stop) always has a cause: low blood sugar, missed seizure pills, stroke, head injury, alcohol withdrawal, poisoning, kidney or liver failure, or electrolytes (like sodium) way out of range. Step one: stabilize ABCs and stop the seizure with benzodiazepines. Step two: hunt for the cause (finger-stick glucose, labs, CT scan, drug screen). Step three: fix the cause. All three steps matter equally.
·After 30 minutes of continuous seizure activity, neurons (brain cells) begin to die from exhaustion and lack of oxygen — even if the shaking has stopped. The longer status epilepticus (a seizure that will not stop) runs, the higher the risk of permanent brain injury, learning problems, and future seizures. Early treatment (within the first 5–20 minutes) changes the whole outcome.
·ABCs come first, always. Open and protect the airway (turn the person on their side, suction if needed). Make sure they are breathing (give oxygen, prepare for possible intubation). Start an IV line. Check blood sugar at the bedside (hypoglycemia can cause or mimic seizures). Then give the benzodiazepine. Order of steps matters in status epilepticus (a seizure that will not stop).

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