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 NICE NG217.
If the patient has an individualised emergency management plan readily available, the specified medication should be administered immediately NICE NG217.
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 NICE NG217.
Concurrent assessment for reversible causes such as hypoglycaemia, eclampsia, or alcohol withdrawal is essential, with appropriate treatment initiated as needed NICE NG217.
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 NICE NG217.
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 NICE NG217.
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 NICE NG217; Rossetti et al. 2024.