Status Epilepticus: When a Seizure Doesn't Stop — A Neurological Emergency

A typical tonic-clonic seizure stops on its own within 1–3 minutes — the brain's inhibitory mechanisms terminate the abnormal discharge. When a seizure continues beyond 5 minutes, it is unlikely to stop spontaneously. Beyond this point, the term status epilepticus (SE) applies. SE is a neurological emergency: prolonged seizure activity causes irreversible neuron death, systemic complications (hyperthermia, metabolic acidosis, hypoxia, rhabdomyolysis), and has a mortality of 10–20% in adults.

Why Seizures Become Status Epilepticus

In established SE, the brain's normal seizure-terminating mechanisms fail: GABA (inhibitory) receptors are internalised away from the synapse; glutamate (excitatory) receptors accumulate. This is why early treatment with benzodiazepines (which act on GABA receptors) is effective — and why the same benzodiazepines become progressively less effective as SE continues. Time is of the essence.

Emergency Treatment Protocol

0–5 minutes: Airway, breathing, circulation. Pulse oximetry. IV access. Blood glucose — give glucose immediately if hypoglycaemic (common, reversible cause). 5–20 minutes (first-line): Benzodiazepine — IV lorazepam (0.1mg/kg, preferred) or IV diazepam (0.15–0.2mg/kg); rectal diazepam or buccal/intranasal midazolam if no IV access (for community use). 20–40 minutes (second-line): IV phenytoin/fosphenytoin, valproate, or levetiracetam — choose based on patient and drug availability. Beyond 40 minutes (refractory SE): Anaesthetic agents (propofol, midazolam infusion, thiopentone coma) with continuous EEG monitoring in ICU.

What Family Members Should Do

If a known epilepsy patient's seizure exceeds 5 minutes — or any seizure that doesn't stop — call 108. If they have prescribed rescue medication (buccal midazolam or rectal diazepam), administer it now. Place the person on their side (recovery position). Do not restrain. Do not put anything in the mouth. Time the seizure — this information is critical for emergency doctors. Sri Anand CNC, Chanda Nagar, Hyderabad. Call +91 90633 66983.