Dr. Sara Gray, an emergency physician and intensivist experienced in critical care education. Rapid, time-focused management of convulsive status epilepticus. Short, clear actions on early benzodiazepine use, avoiding underdosing of second-line drugs, airway and intubation timing, and recognizing non-convulsive seizures when EEG is delayed.
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Manage Eclampsia And Hypertensive Causes Differently
For eclampsia, give a magnesium bolus of 4–6 grams and start an infusion; involve OB immediately.
For hypertensive encephalopathy, prioritize blood pressure control with labetalol or nicardipine.
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Start Second‑Line Drug At Five Minutes
At five minutes of ongoing seizure, add a second-line antiseizure drug while continuing benzos.
Give levetiracetam 60 mg/kg (up to 4.5 g) rapidly—don't underdose it.
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Use High‑Dose Levetiracetam Early
Use levetiracetam preferentially for feasibility and rapid infusion over ~5 minutes.
Expect and give much higher ED loading doses than outpatient regimens.
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Convulsive status epilepticus is one of the most morbid neurologic emergencies we manage in the ED, and outcomes depend far more on speed than drug selection. Like ventricular fibrillation, each minute of ongoing convulsions worsens hypoxia, acidosis, cardiovascular instability, and neuronal injury, while making seizures progressively harder to terminate. Modern definitions are intentionally time-compressed to force early, parallel, clock-anchored action. Any patient still convulsing when you reach the bedside should be treated as evolving status epilepticus.
In this EM Cases podcast with Dr. Sara Gray, we take a practical, time-based approach to convulsive status epilepticus, focusing on early, adequately dosed benzodiazepines, avoiding common escalation and dosing pitfalls, anticipating post-ictal cardiovascular collapse, and knowing when to escalate to second-line agents, airway control, and anesthetic-dose therapy. We also address the transition to non-convulsive status epilepticus and how to recognize ongoing seizures when EEG is not immediately available.
We answer questions such as: Why does time to first benzodiazepine matter more than the drug or route? What critical actions should occur in parallel with the first dose? What are 3 key actions to do in parallel with the first benzodiazepine? Why is underdosing second-line antiseizure medications—especially levetiracetam—a common and dangerous pitfall? When should persistent seizures trigger intubation and anesthetic-dose therapy? How can we identify non-convulsive status epilepticus once tonic-clonic activity stops? And many more (we also include a high yield status epilepticus management algorithm in the show notes!)...
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