Adult Status Epilepticus

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the September 2025 Emergency Medicine Practice article, Emergency Department Management of Patients With Status Epilepticus Topic IntroductionFocus: Status Epilepticus in AdultsReference to recent pediatric episodeArticle authors: Dr. Marquez, Dr. Kaur, Dr. LayWhy Status Epilepticus MattersTeaching value and clinical challengeTeam-based care and multidisciplinary involvementGuidelines and EvidenceReview of major guidelines (International League Against Epilepsy, Neurocritical Care Society, American Epilepsy Society)Key trials: EcLiPSE, ConSEPT, ESETTUpdated definition of status epilepticusClassification and DiagnosisConvulsive vs. non-convulsive statusImportance of repeated neurologic examsDiagnostic challenges and mimics (e.g., syncope, psychogenic seizures)Etiology and WorkupAcute vs. non-acute causesCommon triggers: medication noncompliance, metabolic issues, infections, traumaImportance of sleep patterns and ammonia levelsThe NORSE acronym (new onset refractory status epilepticus)Prehospital and ED ManagementAirway, breathing, circulation prioritiesEarly pharmacologic intervention (IM midazolam preferred in prehospital)Gathering history and medication informationPositioning and airway protectionDiagnosticsLaboratory workup: glucose, CBC, metabolic panel, drug levels, pregnancy testImaging: non-contrast CT, MRI, ultrasound, lumbar punctureEEG: spot vs. continuous monitoringTreatment ApproachFirst-line: Benzodiazepines (lorazepam, midazolam)Second-line: Levetiracetam, valproate, fosphenytoin, phenobarbital, lacosamideThird-line: Continuous infusions (midazolam, propofol, pentobarbital, thiopental, ketamine)Dosing pearls and importance of rapid escalationSpecial PopulationsPregnancy (eclampsia: magnesium as first-line)Substance-induced status epilepticus (e.g., isoniazid toxicity and pyridoxine)Brief mention of pediatric management and the PD stat appRisk Management PitfallsNon-convulsive status is common and easily missedImportance of weight-based dosingNeed for formal EEG in ambiguous casesDon’t assume non-adherence is the only cause in known epilepticsAlways consider higher level of care for status patientsClinical PathwayStepwise approach to medication and escalationEmphasis on having a pathway/checklist for these high-stress casesConclusionRecap of key pointsThanks to authors and listenersReminder to visit ebmedicine.net for CME and resourcesEmergency Medicine Residents, get your free subscription by writing [email protected]