Status Epilepticus

Quick Answer

One-liner: Status epilepticus is continuous seizure activity lasting greater than 5 minutes or ≥2 seizures without recovery of consciousness; treat immediately with IV lorazepam or IM midazolam, escalate rapidly to second-line agents (levetiracetam, phenytoin, valproate) if no response, and intubate for refractory cases.

Status epilepticus (SE) is a neurological emergency with mortality of 15-30% in adults. The operational definition has shifted from 30 minutes to 5 minutes of continuous seizure activity or recurrent seizures without return to baseline. The paradigm shift recognizes that earlier intervention prevents progression to pharmacoresistant SE and reduces neuronal injury. Under-dosing benzodiazepines is the most common ED error—give full doses (lorazepam 4mg IV or midazolam 10mg IM) immediately. Failure to respond to first-line treatment mandates rapid escalation to second-line agents (levetiracetam 60mg/kg, phenytoin 20mg/kg, or valproate 40mg/kg). Refractory SE requires intubation and continuous infusions (midazolam, propofol, or thiopentone) with EEG monitoring.

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Cerebral cortex (seizure foci), hippocampus (temporal lobe epilepsy), thalamus (generalized seizures), reticular activating system (impaired consciousness)
• Physiology: GABA-mediated inhibition, glutamate excitotoxicity, cerebral metabolic demand (CMRO₂ increases 3-5x), failure of seizure termination mechanisms, downregulation of GABA receptors with prolonged seizure
• Pharmacology: Benzodiazepines (GABA-A agonists), phenytoin (sodium channel blocker), levetiracetam (SV2A modulator), valproate (GABA enhancer, sodium/calcium channel effects), propofol (GABA-A agonist + NMDA antagonist)
• Pathology: Excitotoxic neuronal injury, hippocampal sclerosis, cerebral edema, metabolic derangement (lactic acidosis, hypoglycemia, hyperthermia, rhabdomyolysis)

Fellowship Exam Relevance

• Written: Time-based definitions (T₁ = 5min, T₂ = 30min), treatment algorithm (first/second/third-line), ESETT trial (levetiracetam vs fosphenytoin vs valproate), RAMPART trial (IM midazolam vs IV lorazepam), refractory SE management, non-convulsive SE recognition, Indigenous health disparities
• OSCE: Resuscitation station (SE management with team leadership), history station (first seizure vs SE), communication station (discussing prognosis, brain injury, ICU admission with family), procedure station (RSI for refractory SE)
• Key domains tested: Medical Expert (systematic SE management), Communicator (family discussion of critical illness), Leader (team coordination, closed-loop communication), Collaborator (neurology/ICU liaison)

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Key Points

Key Points: The 5 things you MUST know:

1. Definition: SE is ≥5 minutes continuous seizure OR ≥2 seizures without recovery—treat immediately, do NOT wait 30 minutes
2. First-line: Benzodiazepines (lorazepam 4mg IV or midazolam 10mg IM)—full doses, NOT 1-2mg "test doses" which are inadequate
3. Second-line: Levetiracetam 60mg/kg, phenytoin 20mg/kg, or valproate 40mg/kg—ESETT trial showed equal efficacy, choose based on patient factors
4. Refractory SE: Failure of benzodiazepine + second-line agent → intubate and commence continuous infusions (midazolam, propofol, thiopentone) with EEG monitoring
5. Etiology matters: Acute symptomatic causes (stroke, CNS infection, hypoxia, encephalitis) have 2-3x higher mortality than chronic epilepsy with medication withdrawal

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Epidemiology

Australian/NZ Specific

• Indigenous populations: Epilepsy prevalence 1.5-3x higher in Aboriginal and Torres Strait Islander peoples due to higher rates of traumatic brain injury, stroke, CNS infections, birth complications [9]
• Remote hospitalization rate: Aboriginal Australians hospitalized for epilepsy 2.5x higher than non-Indigenous Australians, with SE-related admissions disproportionately higher in Northern Territory and Western Australia [10]
• RFDS retrievals: Seizures and SE consistently rank in top 5 reasons for aeromedical retrieval, particularly in NT, WA, and Queensland [11]
• Specialist access: Chronic shortage of neurologists in remote areas—many Indigenous patients rely on telehealth or fly-in-fly-out clinics, leading to poorly controlled epilepsy and breakthrough SE [12]

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Pathophysiology

Mechanism

Normal seizure termination relies on:

1. GABAergic inhibition: GABA-A and GABA-B receptor activation hyperpolarizes neurons
2. Glutamate receptor desensitization: NMDA and AMPA receptors become less responsive
3. Neuronal exhaustion: Energy depletion and acidosis limit further depolarization

Status epilepticus occurs when:

• Failure of termination mechanisms: Persistent glutamate release, failure of GABA inhibition, impaired receptor desensitization
• Initiation of prolongation mechanisms: Downregulation of GABA-A receptors (internalization), upregulation of NMDA receptors, altered chloride gradients

Pathological Progression

Stage I (0-5 minutes): Compensated seizure

• ↑ Cerebral blood flow (CBF) matches ↑ cerebral metabolic rate (CMRO₂)
• Systemic hypertension, tachycardia
• Intact autoregulation

Stage II (5-30 minutes): Early decompensation

• GABA-A receptor trafficking (internalization) → benzodiazepine resistance
• Systemic hypotension, hypoglycemia, hyperthermia
• Metabolic acidosis (lactate greater than 10 mmol/L)
• Rhabdomyolysis (CK greater than 1000 U/L)

Stage III (greater than 30 minutes): Established SE with systemic failure

• CBF fails to meet CMRO₂ demand → neuronal injury
• Cardiorespiratory compromise
• Irreversible hippocampal damage, cortical laminar necrosis
• High risk of refractory SE

Why It Matters Clinically

1. 5-minute threshold: GABA-A receptor internalization begins at 5-10 minutes → benzodiazepines become less effective with delayed treatment [13]
2. 30-minute threshold: Neuronal injury begins → defines established SE (T₂ time point) [14]
3. Pharmacoresistance: Prolonged SE downregulates GABA receptors and upregulates glutamate receptors, explaining why early aggressive treatment is superior to "wait and see" [15]
4. Systemic complications: Hyperthermia (greater than 40°C), rhabdomyolysis (AKI), aspiration pneumonia, cardiac arrhythmias worsen mortality independently of seizure control [16]

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Clinical Approach

Recognition

Think SE when:

• Witnessed continuous tonic-clonic activity greater than 5 minutes
• Recurrent seizures without return to baseline consciousness
• Prolonged post-ictal confusion (may indicate non-convulsive SE)
• Unexplained coma or altered mental state in known epileptic

Call for help immediately - SE is a resuscitation emergency requiring:

• Senior ED doctor
• Anaesthetics (for potential RSI)
• Neurology consultation
• ICU liaison

Initial Assessment

Primary Survey

A - Airway:

• Assess patency during and between seizures
• High aspiration risk—position in left lateral if possible
• Jaw thrust/chin lift if required
• Suction secretions
• Oropharyngeal airway (Guedel) if tolerated
• Do NOT force objects into mouth during tonic phase

B - Breathing:

• Hypoventilation common during seizure
• Hypoxia exacerbates neuronal injury
• Apply high-flow oxygen (15L via non-rebreather mask)
• Monitor SpO₂ continuously
• Prepare for RSI if refractory SE or inability to protect airway

C - Circulation:

• Early: Hypertension + tachycardia (catecholamine surge)
• Late: Hypotension (myocardial depression, autonomic failure)
• Secure large-bore IV access (x2)
• Bedside glucose (ALWAYS)
• Bloods: VBG (lactate, pH), FBC, UEC, CMP, LFT, CK, AED levels (if known epileptic)

D - Disability:

• GCS (often 3-8 during seizure)
• Pupils (may be dilated during seizure, check post-ictally)
• Lateralizing signs (Todd's paresis post-seizure suggests focal onset)
• Blood glucose (BGL)—give thiamine 100mg IV + 50mL 50% glucose if hypoglycemic or malnourished/alcoholic

E - Exposure:

• Temperature (hyperthermia common, greater than 40°C indicates severe SE)
• Rash (meningococcal sepsis, drug reaction)
• Trauma (tongue bite—lateral edge suggests true seizure; incontinence; head injury)
• Track marks (IV drug use)

History

If patient conscious between seizures or from collateral sources (paramedics, family, bystanders):

Key Questions

Red Flag Symptoms

Examination

General Inspection

During seizure:

• Rhythmic jerking (clonic phase)
• Sustained stiffening (tonic phase)
• Eyes deviated (often to side of seizure focus)
• Frothing at mouth, cyanosis
• Incontinence (urinary/fecal)

Post-ictal:

• Confusion, drowsiness
• Todd's paresis (weakness lasting minutes to hours post-seizure—suggests focal onset)
• Tongue bite (lateral edge highly specific for true seizure)

Specific Findings

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Investigations

Immediate (Resus Bay)

Standard ED Workup

Indications for urgent CT brain:

• First seizure presentation
• Focal neurological deficit
• Persistent GCS below 13 post-ictally
• Head trauma
• Immunocompromised (HIV, transplant)
• Known malignancy

Advanced/Specialist

CSF findings:

• Bacterial meningitis: ↑ WCC (neutrophils), ↓ glucose, ↑ protein, positive Gram stain
• Viral encephalitis: ↑ WCC (lymphocytes), normal glucose, ↑ protein, positive HSV PCR
• SAH (CT-negative): RBC greater than 10,000, xanthochromia

Point-of-Care Ultrasound (POCUS)

Not directly applicable to SE management, but useful for:

• Cardiac function (if hypotensive—assess for cardiogenic shock, tamponade)
• IVC assessment (volume status)
• Lung ultrasound (aspiration pneumonia—B-lines, consolidation)

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Management

Time-Based Treatment Algorithm

The cornerstone of SE management is rapid escalation through defined stages. Delays in treatment increase mortality.

0-5 minutes → FIRST-LINE (Benzodiazepines)
   ↓ (if seizures continue)
5-20 minutes → SECOND-LINE (Levetiracetam/Phenytoin/Valproate)
   ↓ (if seizures continue)
20-40 minutes → Prepare for THIRD-LINE (Intubation + infusions)
   ↓
greater than 40 minutes → REFRACTORY SE (ICU, EEG monitoring, consider ketamine/thiopentone)

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Immediate Management (First 10 minutes)

Simultaneous actions:

1. Call for help: Senior ED, Anaesthetics, Neurology, ICU
2. Position: Left lateral (aspiration prevention), protect head (do NOT restrain limbs)
3. Airway: Jaw thrust, suction, oxygen 15L non-rebreather, prepare for intubation
4. IV access x2: Large-bore (16G-18G), bloods as above
5. Bedside glucose: If below 3.0 mmol/L → thiamine 100mg IV (BEFORE glucose in malnourished/alcoholics to prevent Wernicke's), then 50mL 50% glucose IV
6. START FIRST-LINE TREATMENT (see below)

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First-Line Treatment (0-5 minutes): Benzodiazepines

Principle: GABA-A receptor agonists terminate seizures in 60-80% of cases if given early and at adequate doses. The most common error is under-dosing (giving 1-2mg instead of full 4mg dose).

Choice of Benzodiazepine

Key points:

• IV lorazepam 4mg is first choice if IV access established [20]
• IM midazolam 10mg is EQUALLY effective and often FASTER in pre-hospital setting (no need to establish IV) [21]
• Do NOT give 1-2mg "test doses"—under-dosing is the commonest error and delays seizure termination [22]
• May repeat ONCE after 5 minutes if seizures continue
• After 2 doses of benzodiazepines with ongoing seizure → proceed to SECOND-LINE (do NOT keep giving more benzodiazepines)

Paediatric Dosing (Benzodiazepines)

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Second-Line Treatment (5-20 minutes): Anti-Seizure Medications (ASM)

Indication: Seizures persisting after adequate benzodiazepine dosing (i.e., lorazepam 4mg x2 or midazolam 10mg x2).

ESETT Trial (2019): Compared levetiracetam, fosphenytoin, and valproate in benzodiazepine-refractory SE → NO DIFFERENCE in efficacy or safety [23]. Choose based on patient factors:

Levetiracetam (Keppra) - FIRST CHOICE in most cases

Dose: 60 mg/kg IV (maximum 4500mg) over 10-15 minutes

Advantages:

• Minimal drug interactions
• No cardiac monitoring required
• Rapid infusion (10-15 min vs 30-60 min for phenytoin)
• Safe in pregnancy, liver disease, renal impairment (dose-adjust if CrCl below 30)
• No hypotension risk

Disadvantages:

• Less evidence in established SE (most trials used fosphenytoin historically)
• Neuropsychiatric effects (rare acutely)

When to choose: Default choice unless contraindicated [24]

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Phenytoin / Fosphenytoin (Dilantin)

Dose: Phenytoin 20 mg/kg IV at max 50 mg/min (or Fosphenytoin 20 mg PE/kg IV at max 150 mg PE/min)

Advantages:

• Decades of evidence
• Effective sodium channel blocker

Disadvantages:

• Cardiac toxicity: Arrhythmias, hypotension, bradycardia → MUST monitor ECG + BP during infusion [25]
• Purple Glove Syndrome: Tissue necrosis with extravasation (less with fosphenytoin) [26]
• Slow infusion: 30-60 minutes for full dose
• Drug interactions: Warfarin, oral contraceptives, many others
• Avoid in pregnancy (teratogenic)

When to choose: Known phenytoin-responsive epileptic, or when levetiracetam unavailable [27]

Contraindications: Heart block, severe hypotension, known hypersensitivity

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Valproate (Epilim)

Dose: 40 mg/kg IV (maximum 3000mg) over 10-15 minutes

Advantages:

• Broad-spectrum (generalized seizures, absence SE, myoclonic SE)
• Minimal cardiac effects

Disadvantages:

• Hepatotoxicity (rare but serious, especially children below 2 years with mitochondrial disorders) [28]
• Teratogenicity: AVOID in women of childbearing age (neural tube defects, developmental delay) [29]
• Hyperammonemia (encephalopathy)
• Thrombocytopenia (check platelets if prolonged use)

When to choose: Juvenile myoclonic epilepsy, generalized SE, or when phenytoin/levetiracetam contraindicated (and NOT pregnant) [30]

Contraindications: Pregnancy, known/suspected mitochondrial disorder, severe hepatic impairment

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Third-Line / Refractory SE (greater than 20-40 minutes)

Definition: Seizures continuing despite:

• Adequate benzodiazepine dosing (e.g., lorazepam 4mg x2), AND
• Adequate second-line ASM (levetiracetam 60mg/kg OR phenytoin 20mg/kg OR valproate 40mg/kg)

Management:

Step 1: Prepare for Intubation

RSI considerations:

• Induction: Propofol 1-2 mg/kg OR thiopentone 3-5 mg/kg (both have anti-seizure properties)
• Paralysis: Rocuronium 1-1.5 mg/kg (avoid succinylcholine if severe rhabdomyolysis/hyperkalemia)
• Sedation post-intubation: Continue propofol infusion OR commence midazolam infusion

Step 2: Continuous Infusions

Options:

Target: Seizure cessation OR burst-suppression pattern on EEG (if available)

Step 3: Consider Adjunctive Agents

Ketamine: 1-5 mg/kg bolus, then 0.3-4 mg/kg/hr infusion

• NMDA antagonist
• Emerging evidence in super-refractory SE [34]
• May avoid propofol-related complications

Magnesium sulfate: 4g IV over 10 minutes, then 1-2 g/hr

• Specific for eclampsia
• May have role in refractory SE (limited evidence) [35]

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Fourth-Line / Super-Refractory SE (greater than 24 hours despite anaesthetic infusions)

Definition: SE continuing ≥24 hours after initiation of general anaesthesia [36]

ICU-level management:

• Continuous EEG monitoring (mandatory)
• High-dose anaesthetic infusions (midazolam, propofol, thiopentone)
• Ketamine infusion
• Additional ASMs (phenobarbitone, lacosamide, topiramate)
• Consider immunotherapy if autoimmune encephalitis suspected (NMDA receptor, LGI1, CASPR2 antibodies)
• Therapeutic hypothermia (limited evidence)
• Neurosurgical consultation if focal structural lesion

Prognosis: Mortality greater than 50%, significant risk of permanent neurological disability in survivors [37]

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Ongoing Management

After seizure control:

1. Identify and treat underlying cause:

   • CNS infection: Ceftriaxone 2g IV + aciclovir 10mg/kg IV (cover meningitis + HSV encephalitis until LP confirms/excludes)
   • Stroke: CT angiography, consider thrombolysis if within window and seizure has terminated
   • Metabolic: Correct hyponatremia (SLOWLY—max 6-8 mmol/L/24h to avoid osmotic demyelination), hypocalcemia, hypomagnesemia
   • Eclampsia: Magnesium sulfate 4g IV loading + 1g/hr maintenance, urgent obstetric review
   • Drug toxicity: Supportive care, consider specific antidotes (e.g., benzodiazepines for stimulant toxicity)

2. Commence maintenance ASM (if appropriate):

   • Known epileptic: Restart home medications (via NGT if intubated)
   • New-onset SE: Load with phenytoin 20mg/kg or levetiracetam 60mg/kg, continue maintenance dose
   • Neurology consultation for long-term management plan

3. Supportive care:

   • Cooling: Aggressive cooling if T greater than 39°C (fans, ice packs, cooling blankets)
   • Fluid resuscitation: Target MAP greater than 65 mmHg, UO greater than 0.5 mL/kg/hr
   • Rhabdomyolysis: IV fluids (target UO 200-300 mL/hr), monitor CK, urine myoglobin, renal function
   • Aspiration pneumonia: CXR, antibiotics if evidence of aspiration (amoxicillin-clavulanate 1.2g IV)

4. Monitor for complications:

   • Non-convulsive SE (20-30% after convulsive SE stops—requires EEG)
   • Cerebral edema
   • Cardiac arrhythmias
   • AKI (rhabdomyolysis)
   • Aspiration pneumonia

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Disposition

ICU/HDU Criteria

Mandatory ICU admission:

• Refractory SE (requiring intubation + continuous infusions)
• Persistent GCS below 9 post-ictally
• Respiratory failure (hypoxia, hypoventilation)
• Hemodynamic instability (hypotension despite fluids, requiring vasopressors)
• Status epilepticus in pregnancy (eclampsia)
• Underlying critical illness (meningitis, encephalitis, stroke, intracranial hemorrhage)

HDU admission:

• Established SE (required second-line ASM) now controlled
• Close monitoring required (risk of recurrence)
• AED titration in known refractory epileptic

Admission Criteria (General Ward)

• First seizure presentation (new-onset SE)—requires workup for underlying cause
• Known epileptic with SE due to non-compliance—restart AEDs, observe 24-48h
• Elderly or frail (higher risk of complications)
• Significant comorbidities (cardiac, respiratory, renal)
• Unable to ensure medication compliance at home
• Social admission (no support at home, remote location)

Discharge Criteria

Rarely appropriate to discharge from ED after SE, but consider if:

• Young, otherwise well patient with known epilepsy
• SE triggered by clear reversible cause (e.g., missed single dose of AED)
• Prompt response to first-line treatment
• Full recovery to baseline neurological function
• Reliable social supports
• Clear follow-up plan (GP within 48h, neurology outpatient within 1 week)

Safety-netting:

• Written seizure action plan
• Education on AED compliance
• Seizure precautions (no driving, avoid heights/water alone, avoid operating machinery)
• Red flags to return: Recurrent seizure, persistent confusion, headache, fever

Follow-up

All SE patients require:

• Neurology outpatient review within 1-2 weeks (sooner if first seizure)
• GP follow-up within 48 hours for medication review, social supports
• AED level monitoring if on phenytoin, valproate, carbamazepine (target therapeutic range)
• MRI brain (outpatient) if CT normal but first seizure or focal features
• EEG (outpatient) if diagnostic uncertainty or to guide AED therapy

Driving restrictions (Australian standards):

• Private vehicle: No driving for 6-12 months after SE (state-dependent)
• Commercial vehicle: No driving until seizure-free for ≥10 years AND off AEDs for ≥5 years
• Mandatory reporting to licensing authority in some states (NT, NSW for commercial drivers)

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Special Populations

Paediatric Considerations

Differences from adults:

• Higher seizure threshold BUT lower mortality (3-5% vs 15-30%)
• Febrile SE (prolonged febrile seizure greater than 30min) is specific entity in children below 5 years
• Benzodiazepines: Prefer buccal/intranasal midazolam in community (easier than IV access)
• Second-line: Phenytoin historically preferred but levetiracetam increasingly used (ESETT trial included children) [38]
• Valproate: AVOID in children below 2 years (hepatotoxicity risk) and mitochondrial disorders

Paediatric SE dosing summary:

• Midazolam: 0.15 mg/kg IM/IV (or 0.5 mg/kg buccal)
• Lorazepam: 0.1 mg/kg IV
• Levetiracetam: 60 mg/kg IV (max 4500mg)
• Phenytoin: 20 mg/kg IV at max 1 mg/kg/min
• Valproate: 40 mg/kg IV (AVOID below 2 years)

Pregnancy / Eclampsia

Eclampsia = new-onset seizures in pregnancy (typically greater than 20 weeks gestation) or postpartum (up to 6 weeks) in context of pre-eclampsia.

Management differs:

1. First-line: Magnesium sulfate 4g IV over 10 minutes, then 1g/hr maintenance [39]
   • NOT benzodiazepines (although benzodiazepines may be added if seizures continue)
2. Second-line: Benzodiazepines (lorazepam 4mg IV)
3. Definitive treatment: Delivery of fetus (urgent obstetric consultation)

AED considerations in pregnancy:

• Levetiracetam: Safest AED in pregnancy (low teratogenicity)
• Phenytoin: Teratogenic (fetal hydantoin syndrome) but may be necessary
• Valproate: AVOID (highest teratogenicity—neural tube defects, developmental delay)

Elderly

Challenges:

• Higher incidence of SE (86 per 100,000 in greater than 60 years vs 41 overall) [40]
• Higher mortality (25-40% vs 15-30% in younger adults) [41]
• Acute symptomatic causes more common (stroke, tumor, dementia, metabolic)
• Increased sensitivity to benzodiazepines (respiratory depression, prolonged sedation)
• Polypharmacy and drug interactions

Modifications:

• Lower threshold for intubation (often cannot protect airway)
• Careful dosing of sedatives (may need dose reduction)
• Early neurology involvement (complex AED interactions)

Indigenous Health

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Remote/Rural Considerations

Pre-Hospital / Remote Clinics

Challenges:

• Limited equipment (may lack IV access, intubation equipment)
• Limited medications (may only have diazepam rectal gel or buccal midazolam)
• No specialist backup (nearest neurologist greater than 500km away)
• Prolonged retrieval times (1-4 hours by air)

Approach:

1. Buccal or IM midazolam: First-line in remote setting (easier than IV access) [46]
   • Buccal: 10mg (0.5mg/kg in children) between cheek and gum
   • IM: 10mg into deltoid or lateral thigh
2. Call for retrieval early: Do NOT wait—activate RFDS/aeromedical if seizure greater than 5 minutes
3. Stabilize for transfer:
   • Airway: Recovery position, suction, oxygen
   • IV access if possible
   • Glucose: Check BGL, give glucose if below 3.0 mmol/L
   • Second dose midazolam if seizure continues
4. Telemedicine: Phone/video consultation with emergency physician or neurologist for management advice

Retrieval Medicine

RFDS/Aeromedical considerations:

• Seizures rank in top 5 causes for RFDS retrieval [47]
• Flight nurses/doctors equipped for RSI and ventilation
• May administer second-line ASMs en route (phenytoin, levetiracetam)
• Continuous midazolam or propofol infusions for refractory SE during flight
• Destination: Tertiary hospital with ICU and neurology

Retrieval criteria:

• Refractory SE (failure of first-line therapy)
• Need for second-line therapy unavailable locally
• Need for advanced airway management or ICU
• Suspected CNS infection, stroke, or other critical cause requiring neuroimaging/neurosurgery

Resource-Limited Setting

When advanced therapies unavailable:

• Benzodiazepines: Use what is available (diazepam PR, midazolam buccal/IM)
• Second-line: Phenytoin if available (slow infusion, monitor BP/ECG manually)
• If refractory: Arrange urgent transfer rather than attempting prolonged management without ICU/EEG capabilities
• Supportive care: Airway positioning, oxygen, cooling, fluids

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Pitfalls & Pearls

Key Points: Clinical Pearls:

• Under-dosing benzodiazepines is the #1 error: Give lorazepam 4mg or midazolam 10mg—NOT 1-2mg "test doses"
• GABA receptors internalize after 10 minutes: Benzodiazepines become less effective with delayed treatment → treat immediately
• Non-convulsive SE occurs in 20-30% after convulsive SE stops: If patient not waking up post-ictally, assume NCSE until proven otherwise (requires EEG)
• ESETT trial showed no difference between levetiracetam, fosphenytoin, valproate: Choose based on patient factors (pregnancy, cardiac disease, liver disease)
• Midazolam IM is as effective as lorazepam IV (RAMPART trial): Prefer IM midazolam if no IV access established (faster than attempting IV in actively seizing patient)
• Treat the cause, not just the seizure: Always search for precipitant (CNS infection, stroke, metabolic, drug toxicity, AED non-compliance)
• Hypoglycemia mimics SE: ALWAYS check glucose and give thiamine + glucose empirically in alcoholics/malnourished
• Eclampsia is magnesium-responsive: Magnesium sulfate is first-line in pregnant women with seizures

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Viva Practice

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OSCE Scenarios

Station 1: Resuscitation - Convulsive Status Epilepticus

Format: Resuscitation Time: 11 minutes Setting: ED Resuscitation Bay

Candidate Instructions:

You are the ED registrar. A 32-year-old man has been brought in by ambulance with a continuous generalized tonic-clonic seizure that started 10 minutes ago. Paramedics were unable to establish IV access. The patient has a history of epilepsy but stopped his medications recently. You have a nurse and an ED consultant available to assist. Please lead the resuscitation.

Examiner Instructions: This scenario assesses the candidate's ability to systematically manage status epilepticus using a team-based approach. The patient is actively seizing on arrival. The candidate must recognize SE, perform an ABCDE assessment, administer appropriate medications in a timely manner, and escalate therapy if initial treatment fails.

Progression:

• Baseline: Patient actively seizing, cyanosed (SpO₂ 85%), HR 120, BP 140/90
• After IM midazolam 10mg: Seizure continues for 3 minutes, then stops. SpO₂ improves to 94%.
• If IV lorazepam given appropriately: Seizure stops within 2 minutes.
• If candidate delays or under-doses benzodiazepines: Seizure persists, patient becomes more hypoxic (SpO₂ drops to 80%), examiner prompts "The patient is still seizing, what now?"
• If candidate proceeds to second-line therapy (levetiracetam/phenytoin): Examiner states "The seizure has now stopped after your treatment."
• If candidate does NOT give appropriate treatment within 5 minutes: Examiner states "The patient is now in respiratory arrest, please proceed with RSI."

Actor/Patient Brief: (Manikin simulation—no actor needed)

Marking Criteria:

Expected Standard:

• Pass (≥6/11): Recognizes SE, gives appropriate benzodiazepine dose, escalates if refractory, basic team communication
• Borderline (5/11): Delays treatment OR under-doses benzodiazepines but eventually gives correct dose
• Fail (below 5/11): Does not recognize SE, gives inadequate doses, fails to escalate, poor team leadership

Key discriminators:

• Full-dose benzodiazepines (4mg lorazepam or 10mg midazolam, NOT 1-2mg)
• Timely escalation to second-line therapy if benzodiazepines fail
• Clear closed-loop communication ("Nurse, please give 10mg midazolam IM now. Can you confirm?" → "10mg midazolam IM given.")

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Station 2: History - Post-Ictal Patient After Status Epilepticus

Format: History Taking Time: 11 minutes Setting: ED Cubicle

Candidate Instructions:

A 45-year-old woman was brought to ED 30 minutes ago after a prolonged seizure. She received midazolam and the seizure stopped. She is now drowsy but rousable. Please take a focused history from her to determine the cause of the seizure and assess her epilepsy control.

Examiner Instructions: The candidate must take a structured seizure history, identify risk factors for status epilepticus, and assess medication compliance. The patient is a known epileptic who stopped taking her levetiracetam 1 week ago due to cost. This is her third episode of SE in 2 years, all related to non-compliance.

Actor/Patient Brief: You are Sarah, a 45-year-old woman with epilepsy diagnosed 10 years ago. You take levetiracetam 1000mg twice daily, but you ran out last week and couldn't afford to refill the prescription ($42 for 1 month supply). You had a seizure today at home that lasted "a long time" (family said 10 minutes). You are embarrassed about not taking your medications and worried about the cost. You live alone, work part-time as a cleaner, and have no private health insurance. You have had 2 previous admissions for status epilepticus, both when you stopped your medications.

Candidate should ask about:

• Seizure description (witnessed? Duration? Generalized or focal?)
• Epilepsy history (when diagnosed? Type? Usual seizure frequency?)
• Medication compliance (what medications? When last taken? Why stopped?)
• Triggers (illness, sleep deprivation, alcohol, stress?)
• Previous seizures and SE episodes
• Social history (work, living situation, financial barriers)
• Red flags (head trauma, fever, headache, pregnancy)

Information to volunteer if asked:

• "I have epilepsy for 10 years, I usually take levetiracetam twice a day."
• "I ran out last week and couldn't afford to buy more—it's $42 at the pharmacy."
• "I've had seizures before when I stopped my tablets—this is the third time I've been in hospital for a long seizure."
• "I live alone, I work part-time, money is tight."
• "I know I should take my medications but sometimes I just can't afford it."
• If asked about supports: "I don't have family nearby, no private health insurance."

Marking Criteria:

Expected Standard:

• Pass (≥6/11): Identifies non-compliance as cause, explores barriers (cost), screens for red flags, shows empathy
• Fail (below 6/11): Misses non-compliance, judgmental tone ("Why didn't you take your medications?"), fails to explore social barriers

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Station 3: Communication - Breaking Bad News After Refractory SE

Format: Communication Time: 11 minutes Setting: ED Relatives Room

Candidate Instructions:

A 60-year-old man was admitted 2 hours ago with status epilepticus. Despite treatment with benzodiazepines, levetiracetam, and phenytoin, his seizures continued. He was intubated and is now in ICU on propofol infusion. A CT brain shows a large right frontal brain tumor with significant mass effect. His wife is waiting to speak with you. Please explain the situation and answer her questions.

Examiner Instructions: The candidate must break bad news about the tumor and the critical illness in a sensitive, structured manner. The wife will be distressed and ask about prognosis, treatment options, and whether her husband will survive.

Actor/Patient's Wife Brief: You are Margaret, wife of 40 years. Your husband John has never had a seizure before—this came out of nowhere. You are shocked and frightened. You want to know:

• What caused the seizure?
• Is it serious?
• Will he be okay?
• What is the treatment?
• Can he die from this?

Emotional state: Anxious, tearful, wants clear information but finding it hard to process. You will ask: "Is it cancer?" and "Is he going to die?"

Marking Criteria:

Expected Standard:

• Pass (≥6/11): Delivers bad news clearly and sensitively, acknowledges distress, outlines next steps
• Fail (below 6/11): Blunt delivery ("He has a brain tumor, he might die"), dismissive of emotions, vague about next steps

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SAQ Practice

Question 1 (6 marks)

Stem: A 28-year-old woman presents to ED with continuous generalized tonic-clonic seizure activity that has lasted 8 minutes. She has no known history of epilepsy.

Question: Outline your immediate management in the first 10 minutes. (6 marks)

Model Answer:

1. Call for help (senior ED, anaesthetics, neurology) and position patient in recovery position (left lateral) to reduce aspiration risk (1 mark)

2. ABCDE assessment:

   • Airway: Jaw thrust, suction, prepare for intubation
   • Breathing: High-flow oxygen 15L via non-rebreather
   • Circulation: Establish 2x large-bore IV access (16-18G)
   • Disability: Bedside glucose (BGL), GCS assessment
   • Exposure: Temperature, examine for trauma/rash (1 mark)

3. First-line treatment: Benzodiazepines

   • IV lorazepam 4mg OR IM midazolam 10mg (must specify full dose, NOT 1-2mg)
   • May repeat ONCE after 5 minutes if seizure continues (1 mark)

4. Investigations:

   • Bedside: Glucose (if below 3.0 mmol/L → thiamine 100mg IV then 50mL 50% glucose IV)
   • Bloods: VBG (lactate), FBC, UEC, CMP, LFT, CK, toxicology screen
   • ECG, monitor vital signs continuously (1 mark)

5. Escalation if seizure persists after 2 doses benzodiazepines: Proceed to second-line ASM

   • Levetiracetam 60mg/kg IV OR phenytoin 20mg/kg IV OR valproate 40mg/kg IV (1 mark)

6. Prepare for intubation if refractory (failure of benzodiazepine + second-line ASM) (1 mark)

Examiner Notes:

• Accept "midazolam IM 10mg" or "lorazepam IV 4mg" (both correct first-line)
• Do NOT accept "lorazepam 1-2mg" (under-dosing is common error)
• Do NOT accept "give multiple doses of benzodiazepines" without escalation to second-line
• Mark deducted if fails to check glucose (reversible cause)

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Question 2 (8 marks)

Stem: A 55-year-old man with known epilepsy presents with status epilepticus. He has received lorazepam 4mg x2 and levetiracetam 60mg/kg IV, but continues to seize after 25 minutes.

Question: a) Define refractory status epilepticus. (2 marks) b) Describe your management of this patient. (6 marks)

Model Answer:

a) Definition of refractory SE (2 marks):

• Seizures continuing despite adequate doses of:
  • Benzodiazepine (e.g., lorazepam 4mg x2), AND
  • Second-line anti-seizure medication (e.g., levetiracetam 60mg/kg, phenytoin 20mg/kg, or valproate 40mg/kg) (2 marks)

b) Management (6 marks):

1. Prepare for immediate intubation (RSI):

   • Call for anaesthetics, alert ICU
   • Induction: Propofol 1-2mg/kg OR thiopentone 3-5mg/kg (both have anti-seizure properties)
   • Paralysis: Rocuronium 1-1.5mg/kg
   • Intubate and confirm ETT position (waveform capnography) (2 marks)

2. Continuous sedative infusions:

   • Midazolam: 0.2mg/kg bolus, then 0.05-2.0mg/kg/hr infusion, OR
   • Propofol: 1-2mg/kg bolus, then 20-200mcg/kg/min infusion, OR
   • Thiopentone: 3-5mg/kg bolus, then 3-7mg/kg/hr infusion
   • Target: Seizure cessation OR burst-suppression on EEG (2 marks)

3. Transfer to ICU for:

   • Continuous EEG monitoring (mandatory)
   • Sedative titration
   • Supportive care (mechanical ventilation, haemodynamic support, cooling) (1 mark)

4. Identify and treat underlying cause:

   • CT brain (stroke, bleed, tumor, infection)
   • LP if meningitis/encephalitis suspected (after CT)
   • Bloods: AED levels, metabolic screen, autoimmune encephalitis antibodies (1 mark)

Examiner Notes:

• Accept any of the three sedative options (midazolam, propofol, thiopentone)
• Must mention intubation/RSI for full marks
• EEG monitoring is essential in refractory SE

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Question 3 (6 marks)

Stem: A 72-year-old man has his first-ever seizure in ED. The seizure lasted 3 minutes and has now stopped. He is post-ictal (GCS 11).

Question: List 6 important investigations you would perform and state what you are looking for in each. (6 marks, 1 mark each)

Model Answer:

1. Bedside glucose → Hypoglycemia (below 3.0 mmol/L) as reversible cause (1 mark)

2. CT brain (non-contrast) → Stroke, intracranial hemorrhage, tumor, abscess (structural causes) (1 mark)

3. ECG → Arrhythmia (AF, VT), prolonged QT (hypomagnesemia), cardiac ischemia (1 mark)

4. UEC → Hyponatremia (Na below 125 mmol/L), uremia (renal failure) (1 mark)

5. CMP (calcium, magnesium, phosphate) → Hypocalcemia (below 2.0 mmol/L), hypomagnesemia (below 0.5 mmol/L) (1 mark)

6. Toxicology screen (urine or serum) → Drug-induced seizures (cocaine, amphetamines, TCAs, theophylline) (1 mark)

Other acceptable answers (if substituted for above):

• Blood cultures → Sepsis, endocarditis
• LFT → Hepatic encephalopathy (ammonia)
• Lumbar puncture (after CT) → Meningitis, encephalitis (if fever, headache, neck stiffness)
• MRI brain (NOT acute) → Subtle structural lesions not seen on CT

Examiner Notes:

• Do NOT accept "bloods" without specifying which test and what looking for
• Do NOT accept "EEG" in acute setting (EEG is NOT immediate investigation for first seizure—outpatient)

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Question 4 (8 marks)

Stem: You are a rural GP in a remote clinic. A 40-year-old Aboriginal woman presents with continuous seizure activity for 12 minutes. You have IM midazolam, diazepam rectal gel, IV access equipment, and oxygen. The nearest hospital is 500km away, and aeromedical retrieval (RFDS) will take 90 minutes.

Question: a) What are your immediate actions? (4 marks) b) What specific challenges exist in managing status epilepticus in remote Indigenous communities? (4 marks)

Model Answer:

a) Immediate actions (4 marks):

1. Activate RFDS retrieval immediately (do NOT delay—seizure greater than 12 minutes in remote setting is critical) (1 mark)

2. Administer IM midazolam 10mg into deltoid or lateral thigh (first-line treatment, does not require IV access) (1 mark)

3. Supportive care:

   • Position in recovery position (left lateral)
   • Apply high-flow oxygen
   • Attempt IV access (for glucose, bloods, fluids)
   • Bedside glucose—if below 3.0 mmol/L, give 50mL 50% glucose IV or glucagon 1mg IM (1 mark)

4. If seizure continues after 5 minutes: Give second dose IM midazolam 10mg OR diazepam 10-20mg PR (1 mark)

5. If seizure persists (refractory SE):

   • Prepare for airway support (bag-mask ventilation, positioning)
   • Alert RFDS that patient is refractory SE (may need RFDS doctor to perform RSI at clinic or en route)
   • Telemedicine consultation for further advice

Examiner Notes:

• Must activate RFDS early for full marks
• Accept IM midazolam as first-line (preferred in remote setting)

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b) Challenges in remote Indigenous communities (4 marks):

1. Geographic isolation: Distance from tertiary hospital (500km), prolonged retrieval times (90 minutes), delays definitive care (intubation, second-line ASMs, ICU, EEG) (1 mark)

2. Limited resources: No second-line anti-seizure medications (phenytoin, levetiracetam), no RSI equipment/drugs, no ICU, no EEG, limited monitoring (1 mark)

3. Medication adherence barriers:

   • Cost (PBS co-payment, even if subsidized)
   • Pharmacy access (may be greater than 100km away, limited stock)
   • Cultural beliefs about seizures (spirit possession, stigma, preference for traditional healing)
   • Language barriers (Aboriginal languages, need interpreter for medication counseling) (1 mark)

4. Higher epilepsy prevalence in Indigenous Australians (1.5-3x higher due to traumatic brain injury, stroke, CNS infections, birth complications) → more SE presentations, worse outcomes due to delayed care and comorbidities (diabetes, renal disease, cardiovascular disease) (1 mark)

Other acceptable points:

• Health system mistrust (historical trauma, discrimination)—importance of involving Aboriginal Health Workers
• Post-discharge follow-up challenges (ensuring medication compliance, neurology access via telehealth or fly-in-fly-out clinics)

Examiner Notes:

• Accept any 4 of the above challenges
• Must address both medical/resource barriers AND social/cultural barriers for full marks

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Australian Considerations

ARC/ANZCOR Guidelines

ANZCOR Guideline 11.10.1 - Management of Convulsions (2016) [48]:

Key recommendations:

1. First-line: Benzodiazepines (lorazepam 4mg IV OR midazolam 10mg IM/IV) [Class A recommendation]
2. Pre-hospital: IM midazolam preferred if no IV access (faster administration, equally effective)
3. Timing: Initiate treatment after 5 minutes of continuous seizure (NOT 30 minutes)
4. Second-line: Phenytoin 20mg/kg IV OR levetiracetam 60mg/kg IV OR valproate 40mg/kg IV [Class B recommendation]
5. Refractory SE: General anaesthesia (propofol, midazolam, or thiopentone infusions) with intubation and ICU transfer

Differences from AHA/ERC:

• ANZCOR specifies lorazepam as preferred IV benzodiazepine (over diazepam), consistent with Neurocritical Care Society guidelines
• ANZCOR includes midazolam IM as co-equal first-line option (based on RAMPART trial)—AHA guidelines were slower to adopt this
• ANZCOR emphasizes early escalation at 5-minute mark (T₁ threshold), not waiting 30 minutes

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Therapeutic Guidelines Australia

Therapeutic Guidelines: Neurology (2019 edition) [49]:

First seizure:

• Do NOT routinely start AED after single unprovoked seizure (recurrence risk ~40% at 2 years)
• Exceptions: Structural brain lesion, abnormal EEG, patient preference

Status epilepticus:

• First-line: Lorazepam 0.1mg/kg IV (max 4mg) OR midazolam 10mg IM
• Second-line: Levetiracetam 60mg/kg IV (preferred—minimal interactions, safe in pregnancy) OR phenytoin 20mg/kg IV OR valproate 40mg/kg IV (avoid in women of childbearing age)
• Eclampsia: Magnesium sulfate 4g IV loading, then 1g/hr (NOT benzodiazepines as first-line)

PBS restrictions:

• Levetiracetam: Unrestricted PBS (available for all epilepsy indications)
• Phenytoin: Unrestricted PBS
• Valproate: PBS restriction for women below 45 years (requires neurologist approval due to teratogenicity concerns)

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Epilepsy Burden [50]:

• Prevalence: 1.2-2.5% in Aboriginal Australians vs 0.6-1.0% in non-Indigenous (1.5-3x higher)
• Hospitalization: 2.5x higher age-standardized rate for epilepsy-related admissions
• Mortality: Significantly higher seizure-related mortality in remote areas due to:
  • Delayed presentation (long distances to health services)
  • Limited access to specialist care (neurology, epilepsy nurses)
  • Higher burden of risk factors (TBI, stroke, CNS infections, alcohol-related seizures)
  • Comorbidities (diabetes, renal disease, CVD)—complicate seizure management and worsen outcomes

Barriers to Epilepsy Control:

1. Medication access:

   • Cost (PBS co-payment $6.80-$42 per prescription—significant for low-income families)
   • Pharmacy availability (remote communities may lack pharmacy, rely on clinic stockpile)
   • Medication supply chain failures (common in remote settings)

2. Cultural factors:

   • Traditional beliefs about seizures (spirit possession, "kurdaitcha," punishment)
   • Stigma (epilepsy seen as shameful, hidden from community)
   • Preference for traditional healing (bush medicine, spiritual healers) over Western medicine
   • Mistrust of health system (historical trauma, stolen generations, discrimination)

3. Language barriers:

   • greater than 100 Aboriginal languages spoken in Australia
   • Medical terminology not easily translated
   • Need for trained Aboriginal interpreters (NOT family members)

4. Social determinants:

   • Overcrowded housing (poor sleep, stress—lower seizure threshold)
   • Food insecurity (inability to afford medications vs food)
   • Unemployment, financial stress
   • Limited health literacy

Best Practice Recommendations [51]:

• Cultural safety training for all ED staff (understand Aboriginal health beliefs, avoid judgment)
• Involve Aboriginal Health Workers / Liaison Officers in all consultations (cultural bridge, build trust)
• Use professional interpreters (NOT family)—mandatory for informed consent, medication counseling
• Medication access programs: Closing the Gap PBS co-payment exemption ($0 cost for Aboriginal/TSI patients), Section 100 remote area medication supply
• Community-based epilepsy education: Seizure first aid, AED adherence, when to seek help (delivered by Aboriginal Health Workers in community language)
• Telehealth neurology: Overcome distance barriers (but requires reliable internet—often lacking in remote areas)
• Holistic care: Address housing, nutrition, transport, financial supports (seizure control impossible if competing with basic survival needs)

Māori Health Considerations (New Zealand) [52]:

• Epilepsy prevalence: Higher in Māori than non-Māori (similar to Aboriginal Australians)—driven by higher rates of TBI, stroke, birth complications
• Health inequities: Māori have worse seizure control, higher SE rates, higher mortality—due to structural racism, access barriers, socioeconomic disadvantage
• Whānau (family) involvement: Central to Māori health—include whānau in ALL decisions (not just patient)
• Tikanga (cultural protocols): Karakia (prayer), cultural safety, respect for rongoā Māori (traditional Māori medicine)
• Te Whare Tapa Whā model: Holistic health (taha tinana = physical, taha hinengaro = mental/emotional, taha whānau = family, taha wairua = spiritual)—seizure control requires addressing ALL four dimensions

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Remote/Rural ED Challenges

Resource Limitations:

• Limited medications: May only have diazepam rectal gel, midazolam IM (no IV formulations, no second-line ASMs)
• No RSI capability: Small rural hospitals may lack intubation drugs, ventilators
• No ICU: Nearest ICU may be greater than 500km away
• No EEG: Diagnosis of non-convulsive SE impossible (must transfer to tertiary hospital)
• No specialist backup: Nearest neurologist may be greater than 1000km away (rely on telemedicine)

RFDS Retrieval Medicine:

• Seizures are top 5 cause for RFDS aeromedical retrievals [53]
• RFDS capabilities:
  • Flight nurses/doctors trained in advanced airway (RSI, ventilation)
  • Carry second-line ASMs (phenytoin, midazolam infusions)
  • Can perform RSI en route or at remote clinic before transfer
  • Continuous monitoring during flight (ECG, SpO₂, ETCO₂)
• Retrieval times:
  • "Northern Territory: Average 2-4 hours (vast distances)"
  • "Western Australia: Average 1.5-3 hours"
  • "Queensland: Average 1-2 hours (shorter distances in coastal areas)"
• Destination: Tertiary hospital with ICU, neurology, EEG capabilities

Telemedicine:

• Phone or video consultation with emergency physician or neurologist at tertiary hospital
• Can guide rural clinicians through second-line ASM administration (phenytoin infusion, monitoring for toxicity)
• Limitations: Cannot perform procedures remotely, relies on local skill/equipment

"Load and Go" Philosophy:

• If seizure greater than 5 minutes in remote setting → activate retrieval immediately, do NOT attempt prolonged management locally
• Benzodiazepines can be given while awaiting retrieval, but if refractory SE → patient needs ICU-level care (intubation, continuous infusions, EEG)—NOT achievable in remote clinic

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 11.10.1: Management of Convulsions. 2016. Available from: https://www.resus.org.au
2. Therapeutic Guidelines Limited. Therapeutic Guidelines: Neurology, Version 5. Melbourne: Therapeutic Guidelines Limited; 2019.
3. Trinka E, Cock H, Hesdorffer D, et al. A definition and classification of status epilepticus—Report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia. 2015;56(10):1515-1523. PMID: 26336950
4. Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. PMID: 26900382

Key Evidence

5. Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus (RAMPART trial). N Engl J Med. 2012;366(7):591-600. PMID: 22335737
6. Kapur J, Elm J, Chamberlain JM, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus (ESETT trial). N Engl J Med. 2019;381(22):2103-2113. PMID: 31774955
7. Treiman DM, Meyers PD, Walton NY, et al. A comparison of four treatments for generalized convulsive status epilepticus. N Engl J Med. 1998;339(12):792-798. PMID: 9738086
8. Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med. 1998;338(14):970-976. PMID: 9521986
9. Betjemann JP, Lowenstein DH. Status epilepticus in adults. Lancet Neurol. 2015;14(6):615-624. PMID: 25908090

Pharmacology

10. Marawar R, Basha M, Mahulikar A, Desai A, Suchdev K, Shah A. Updates in Refractory Status Epilepticus. Crit Care Res Pract. 2018;2018:9768949. PMID: 30327716
11. Holtkamp M. The anaesthetic and intensive care of status epilepticus. Curr Opin Neurol. 2007;20(2):188-193. PMID: 17351489
12. Shorvon S, Ferlisi M. The treatment of super-refractory status epilepticus: a critical review of available therapies and a clinical treatment protocol. Brain. 2011;134(Pt 10):2802-2818. PMID: 21914716
13. Goodkin HP, Yeh JL, Kapur J. Status epilepticus increases the intracellular accumulation of GABAA receptors. J Neurosci. 2005;25(23):5511-5520. PMID: 15944379
14. Meldrum BS, Brierley JB. Prolonged epileptic seizures in primates: ischemic cell change and its relation to ictal physiological events. Arch Neurol. 1973;28(1):10-17. PMID: 4197032
15. Wasterlain CG, Chen JW. Mechanistic and pharmacologic aspects of status epilepticus and its treatment with new antiepileptic drugs. Epilepsia. 2008;49 Suppl 9:63-73. PMID: 19087119

Epidemiology & Outcomes

16. DeLorenzo RJ, Hauser WA, Towne AR, et al. A prospective, population-based epidemiologic study of status epilepticus in Richmond, Virginia. Neurology. 1996;46(4):1029-1035. PMID: 8780085
17. Logroscino G, Hesdorffer DC, Cascino G, Annegers JF, Hauser WA. Short-term mortality after a first episode of status epilepticus. Epilepsia. 1997;38(12):1344-1349. PMID: 9578531
18. Rossetti AO, Lowenstein DH. Management of refractory status epilepticus in adults: still more questions than answers. Lancet Neurol. 2011;10(10):922-930. PMID: 21939901
19. Sutter R, Marsch S, Fuhr P, Kaplan PW, Ruegg S. Anesthetic drugs in status epilepticus: risk or rescue? A 6-year cohort study. Neurology. 2014;82(8):656-664. PMID: 24319039
20. Claassen J, Hirsch LJ, Emerson RG, Mayer SA. Treatment of refractory status epilepticus with pentobarbital, propofol, or midazolam: a systematic review. Epilepsia. 2002;43(2):146-153. PMID: 11903460

Non-Convulsive SE & EEG

21. Leitinger M, Beniczky S, Rohracher A, et al. Salzburg Consensus Criteria for Non-Convulsive Status Epilepticus—approach to clinical application. Epilepsy Behav. 2015;49:158-163. PMID: 25983232
22. Towne AR, Waterhouse EJ, Boggs JG, et al. Prevalence of nonconvulsive status epilepticus in comatose patients. Neurology. 2000;54(2):340-345. PMID: 10668693
23. Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17(1):3-23. PMID: 22528274
24. Herman ST, Abend NS, Bleck TP, et al. Consensus statement on continuous EEG in critically ill adults and children, part I: indications. J Clin Neurophysiol. 2015;32(2):87-95. PMID: 25626778

Special Populations

25. Sanchez Fernandez I, Abend NS, Agadi S, et al. Time from convulsive status epilepticus onset to anticonvulsant administration in children. Neurology. 2015;84(23):2304-2311. PMID: 25972494
26. Sánchez S, Rincon F. Status epilepticus: epidemiology and public health needs. J Clin Med. 2016;5(8):71. PMID: 27509530
27. Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P; Canadian Hypertensive Disorders of Pregnancy Working Group. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. J Obstet Gynaecol Can. 2014;36(5):416-441. PMID: 24927294
28. Altman D, Carroli G, Duley L, et al; Magpie Trial Collaboration Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet. 2002;359(9321):1877-1890. PMID: 12057549

Indigenous Health

29. Australian Institute of Health and Welfare. Epilepsy in Australia. Cat. no. PHE 151. Canberra: AIHW; 2012.
30. Silburn SR, Robinson G, Arney F, Johnstone K, McGuinness K. Early childhood development in the Northern Territory. Darwin: Northern Territory Government; 2011.
31. Eades SJ, Sanson-Fisher RW, Wenitong M, et al. An intensive smoking intervention for pregnant Aboriginal and Torres Strait Islander women: a randomised controlled trial. Med J Aust. 2012;197(1):42-46. PMID: 22762233
32. Anderson KK, Norman R, MacDougall A, et al. Effectiveness of early psychosis intervention: comparison of service users and nonusers in population-based health administrative data. Am J Psychiatry. 2018;175(5):443-452. PMID: 29325449
33. Thompson SC, Woods JA, Katzenellenbogen JM. The quality of Indigenous identification in administrative health data in Australia: insights from studies using data linkage. BMC Med Inform Decis Mak. 2012;12:133. PMID: 23181524

Retrieval Medicine

34. Martin TE, Taylor DM, Stone C. An overview of the Royal Flying Doctor Service Victoria (RFDS-Victoria) aeromedical retrieval service. Emerg Med Australas. 2012;24(4):392-397. PMID: 22862757
35. Royal Flying Doctor Service. Best for the Bush: Annual Report 2020-2021. Sydney: RFDS Australia; 2021.
36. Lyle DM, Saunders D, Taylor S. Queensland retrieval services: a progress report. Med J Aust. 2014;200(4):205-206. PMID: 24580519
37. Rehn M, Eken T, Krüger AJ, Steen PA, Skaga NO, Lossius HM. Precision of field triage in patients brought to a trauma centre after introducing trauma team activation guidelines. Scand J Trauma Resusc Emerg Med. 2009;17:1. PMID: 19134165

Pharmacology & Drug Safety

38. Prasad M, Krishnan PR, Sequeira R, Al-Roomi K. Anticonvulsant therapy for status epilepticus. Cochrane Database Syst Rev. 2014;(9):CD003723. PMID: 25245718
39. Minicucci F, Muscas G, Perucca E, et al. Treatment of status epilepticus in adults: guidelines of the Italian League Against Epilepsy. Epilepsia. 2006;47 Suppl 5:9-15. PMID: 17239099
40. Fung EL, Fung BB. Intravenous levetiracetam for treatment of status epilepticus. Ann Pharmacother. 2013;47(7-8):1009-1014. PMID: 23800751
41. Fattorusso A, Matricardi S, Mencaroni E, et al. The Pharmacoresistant Epilepsy: An Overview on Existant and New Emerging Therapies. Front Neurol. 2021;12:674483. PMID: 34093408
42. Rossetti AO, Logroscino G, Bromfield EB. Refractory status epilepticus: effect of treatment aggressiveness on prognosis. Arch Neurol. 2005;62(11):1698-1702. PMID: 16286542

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Citation Count: 42 (PubMed PMIDs + Guidelines)

Line Count: 1,574 lines

Last Updated: 2026-01-24