What are the initial steps in the emergency management of a patient presenting with status epilepticus?

Initial emergency management of status epilepticus involves immediate resuscitation and administration of first-line antiseizure medication. This begins with ensuring airway patency, breathing, and circulation support, alongside monitoring vital signs and oxygenation to prevent hypoxia and other complications ¹.

If the patient has an individualised emergency management plan readily available, the specified medication should be administered immediately ¹.

In the absence of such a plan, a benzodiazepine should be given promptly as first-line treatment: buccal midazolam or rectal diazepam in the community setting, or intravenous lorazepam if intravenous access and resuscitation facilities are immediately available ¹.

Concurrent assessment for reversible causes such as hypoglycaemia, eclampsia, or alcohol withdrawal is essential, with appropriate treatment initiated as needed ¹.

If the seizure does not stop within 5 to 10 minutes after the first benzodiazepine dose, a second dose should be administered while emergency services are contacted or expert hospital guidance sought ¹.

Should convulsive status epilepticus persist despite two doses of benzodiazepines, second-line intravenous antiseizure medications such as levetiracetam, phenytoin, or sodium valproate are indicated, with levetiracetam often preferred due to quicker administration and fewer adverse effects ¹.

Recent ICU literature emphasizes the critical importance of rapid escalation and continuous monitoring in refractory cases, highlighting that early aggressive management reduces morbidity and mortality (Rossetti et al., 2024).

Overall, the initial steps focus on rapid seizure termination with benzodiazepines, supportive care, identification and treatment of underlying causes, and timely escalation to second-line agents under expert supervision ¹; (Rossetti et al., 2024).