Emergency Department Management of Patients With Status Epilepticus

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Publication Date: September 2025 (Volume 27, Number 9)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 09/01/2028.

Authors

Peer Reviewers

Abstract

Status epilepticus is a neurological emergency requiring prompt intervention by emergency clinicians, as delays can lead to significant morbidity and mortality. Etiologies include acute causes such as electrolyte imbalance, infection, drugs, and acute strokes, as well as chronic causes such as remote brain injury, progressive epilepsies, and brain tumors. This issue presents evidence for an algorithmic approach to status epilepticus, from managing underlying causes and administering initial benzodiazepines, to second-line antiseizure agents, and escalating to intravenous anesthetics for refractory cases. Disposition for patients in status epilepticus includes inpatient care tailored to the patient’s clinical needs, and appropriate follow-up.

Case Presentations

A 65-year-old man presents to the emergency department via EMS, with ongoing tonic-clonic movement of the right face, arm, and leg for the past 25 minutes…

• EMS administered oxygen and 10 mg intramuscular midazolam, without resolution of symptoms. The patient was placed on a monitor, and IV access was obtained.
• Initial vital signs are: temperature, 37.3°C; heart rate, 120 beats/min; blood pressure, 157/90 mm Hg; and oxygen saturation, 98% on 4 L nasal cannula. A point-of-care glucose level is 81 mg/dL.
• After administration of 4 mg IV lorazepam, he stops seizing. You send initial blood work, including CBC, comprehensive metabolic profile, ethanol level, acetaminophen/salicylate level, and lactate, to the laboratory. His wife arrives and provides history that the patient is receiving radiation and chemotherapy for glioblastoma multiforme of the left temporal lobe.
• After 1 hour, the patient is still not responding to questioning or painful stimulus, and his oxygen requirement worsens. He has slight twitching movements of the right face and mouth every 2 minutes.
• You consider whether the patient could still be seizing and, if so, what the best next course of action should be...

A 25-year-old woman presents with her family to the ED with acute onset of paranoid ideation, lateral nystagmus, and stereotypic repetitive “pill rolling” motor activity…

• Her vital signs include: temperature, 37.6°C; heart rate, 110 beats/min; blood pressure, 140/80 mm Hg; and oxygen saturation, 99%.
• In speaking with her family, you note that she has a past psychiatric history that includes episodes of “poor impulse control” and “outbursts of violent behavior toward family members.”
• You consider whether she should be triaged to psychiatry or if something else might be going on…

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.