Summary

The 2012 Neurocritical Care Society guideline provides evidence-based and expert-consensus recommendations for evaluation and acute management of status epilepticus (SE) in critically ill adults and children. SE is operationally defined as ≥5 minutes of continuous seizure activity or recurrent seizures without recovery, and treatment is structured into emergent initial therapy (benzodiazepine), urgent control therapy (IV AED), and refractory SE therapy (continuous IV anesthetic infusion with EEG monitoring). The document emphasizes simultaneous diagnostic workup, early cEEG in patients who do not return to baseline, and protocolized escalation to improve outcomes.

Key Recommendations

Treat SE as any seizure lasting ≥5 minutes or recurrent seizures without return to baseline.
Give a benzodiazepine as emergent first-line therapy in every patient with SE; IV lorazepam preferred, IM midazolam if no IV access.
Immediately follow benzodiazepine with an urgent-control IV antiepileptic (fosphenytoin/phenytoin, valproate sodium, levetiracetam, or phenobarbital) regardless of seizure cessation.
Treat refractory SE (seizures continuing after benzodiazepine plus one urgent AED) with continuous IV infusion of midazolam, propofol, or pentobarbital titrated to seizure suppression or burst-suppression on EEG.
Obtain emergent (≤1 hour) STAT EEG and initiate continuous EEG monitoring in any patient who does not return to baseline within 10 minutes of clinical seizure cessation, in coma, or on IV anesthetic infusion.
Maintain cIV anesthetic for 24–48 hours of seizure control before attempting weaning; restart and uptitrate if seizures recur.
Send STAT glucose, electrolytes, calcium, magnesium, CBC, AED levels, toxicology, and consider LP and head CT/MRI to identify etiology.
Treat pregnant women with eclamptic seizures with IV magnesium sulfate rather than standard AEDs.
Avoid prolonged propofol infusion at high doses in children and monitor for propofol infusion syndrome (metabolic acidosis, rhabdomyolysis, cardiac failure).
Start a maintenance AED concurrently with urgent control therapy to prevent seizure recurrence after anesthetic weaning.

Thresholds & Doses

SE definition: ≥5 min continuous seizure or ≥2 discrete seizures without recovery of consciousness
Lorazepam IV: 0.1 mg/kg (max 4 mg/dose), may repeat once
Midazolam IM: 0.2 mg/kg (max 10 mg) — preferred if no IV access
Diazepam IV: 0.15 mg/kg (max 10 mg/dose), may repeat
Fosphenytoin/phenytoin load: 20 mg PE/kg IV (may give additional 5–10 mg/kg)
Valproate sodium load: 20–40 mg/kg IV (may give additional 20 mg/kg)
Levetiracetam load: 1000–3000 mg IV (or 20–60 mg/kg)
Phenobarbital load: 20 mg/kg IV (may give additional 5–10 mg/kg)
Midazolam cIV: load 0.2 mg/kg, infusion 0.05–2 mg/kg/h
Propofol cIV: load 1–2 mg/kg, infusion 30–200 μg/kg/min (caution >80 μg/kg/min or >48 h — propofol infusion syndrome)
Pentobarbital cIV: load 5–15 mg/kg, infusion 0.5–5 mg/kg/h
cIV anesthetic duration: titrate to seizure suppression or burst-suppression for 24–48 h before wean
Refractory SE: failure of benzodiazepine + one urgent-control AED (regardless of time elapsed)
Magnesium sulfate for eclampsia: 4–6 g IV load then 1–2 g/h

Citations

Brophy et al., Neurocrit Care 2012;17:3–23 — full guideline text
Definition section — SE defined as ≥5 min continuous seizure or ≥2 seizures without recovery
Emergent initial therapy section — benzodiazepine first-line dosing
Urgent control therapy section — second-line AED selection
Refractory SE section — continuous infusion anesthetics and EEG goals
Diagnostic evaluation and EEG monitoring section — cEEG indications
Treiman VA Cooperative Study (ref 30) — lorazepam vs diazepam/phenytoin/phenobarbital
Silbergleit RAMPART trial (ref 84) — IM midazolam vs IV lorazepam prehospital