Neuro ICU > Status Epilepticus

Status Epilepticus (SE)

Status epilepticus is defined as a seizure lasting 5 minutes or longer, or two or more seizures without return to baseline consciousness between episodes. SE is a neurological emergency requiring immediate intervention to prevent permanent brain injury or death.

SE is one of the most common neurological emergencies — approximately 150,000 cases occur annually in the United States, with a mortality rate of 20%. It is frequently encountered in the Neuro ICU as both a primary diagnosis and a complication of other conditions (CVA, TBI, CNS infection, metabolic disturbance).

  • The most recognizable form — characterized by continuous or rapidly recurring tonic-clonic movements. Generalized convulsive SE is the most common and life-threatening subtype. Requires immediate medical intervention.

    • Symptoms: rhythmic jerking movements, loss of consciousness, cyanosis, urinary incontinence, post-ictal confusion

    • Risk: hyperthermia, hypoxia, metabolic acidosis, rhabdomyolysis with prolonged episodes

  • Seizure activity on EEG without obvious motor manifestations. Frequently missed or underdiagnosed — NCSE accounts for up to 25% of all SE cases in the ICU. Patients may appear confused, unresponsive, or behaviorally altered without convulsions.

    • Symptoms: altered consciousness, confusion, staring, subtle eye or facial movements, behavioral changes, aphasia

    • Diagnosis requires EEG — clinical examination alone is insufficient

    • Important: a patient who appears "sleepy" or "encephalopathic" may be in NCSE

  • SE that fails to respond to first- and second-line antiepileptic medications. Requires continuous IV anesthetic infusion and intubation. Associated with significantly higher morbidity and mortality.

    • Super-refractory SE: continues or recurs 24+ hours after anesthetic treatment

    • Common in autoimmune encephalitis, acute brain injury, or febrile illness-related SE

Common Causes of Status Epilepticus

  • Acute symptomatic: stroke (ischemic or hemorrhagic), TBI, CNS infection, metabolic disturbance (hyponatremia, hypoglycemia, uremia), drug toxicity or withdrawal (alcohol, benzodiazepines, AEDs)

  • Remote symptomatic: prior brain injury or insult (epilepsy, prior stroke, prior TBI)

  • Anoxic brain injury (post-cardiac arrest)

  • Autoimmune encephalitis (increasingly recognized — especially anti-NMDA receptor encephalitis)

  • Unknown or cryptogenic

Diagnosis & Monitoring

  • Continuous EEG (cEEG): gold standard for diagnosing NCSE and monitoring treatment response. Patients may be on continuous EEG for days — this directly affects therapy logistics (leads on scalp, wires at bedside)

  • Labs: glucose, electrolytes, AED levels, toxicology screen, CBC, metabolic panel

  • Neuroimaging: MRI or CT to identify the structural cause

  • Lumbar Puncture (LP): if CNS infection or autoimmune encephalitis is suspected

Treatment

  • Lorazepam (IV), diazepam (rectal/IV), or midazolam (IM/buccal). Goal: terminate seizure activity within 5 minutes of onset.

  • Levetiracetam (Keppra), fosphenytoin/phenytoin, or valproate IV. Used if benzodiazepines fail to terminate seizure.

  • Propofol, midazolam infusion, or pentobarbital. Requires intubation and ICU admission. Goal is burst suppression on EEG.

    • Patients in burst suppression are deeply sedated and will not participate in therapy — defer all active therapy until anesthetics are weaned

Activity Decision Framework — Status Epilepticus

Activity parameters depend heavily on seizure control status, EEG findings, medication burden, and post-ictal recovery. Always review EEG status and confirm activity orders with the medical team before initiating therapy.

Tier Clinical Status Guidance
GO Seizures controlled; off continuous anesthetics; returned to baseline or near-baseline mental status; EEG not showing active ictal activity Proceed per activity orders; assess cognition and participation capacity at start of each session — post-ictal effects can persist and fluctuate
MODIFY Recovering from SE; post-ictal fatigue or confusion; high antiepileptic medication burden affecting alertness or cooperation Shorten session; reduce cognitive demand; use familiar, structured tasks; monitor for fatigue and subtle signs of recurring seizure activity (eye deviation, automatisms, unresponsiveness)
YIELD Seizure control uncertain; EEG findings not yet reviewed; NCSE not yet ruled out; recent medication change Confirm seizure control status with nursing or medical team before initiating; review cEEG status if available
DEFER Active SE being treated; on continuous anesthetic infusion (propofol, midazolam drip) for burst suppression; immediate post-ictal period with significantly depressed consciousness Hold all active therapy; passive ROM and positioning may be appropriate if cleared by team; reassess daily as medications are weaned
STOP Seizure occurs during therapy session Stop therapy; protect patient from injury; do not restrain; time the seizure; call for help immediately; do not leave the patient alone; document and notify team

Therapy Implications

  • Know the patient's seizure history before entering the room — type of seizure, typical presentation, frequency, and whether auras occur. Review the chart for recent seizure activity and current antiepileptic regimen.

  • Aura awareness: If the patient has a known aura, return the patient to bed as quickly and safely as possible at first sign of one. If unable to get to bed, lay the patient on the nearest safe surface and protect the head.

  • If the patient has frequent seizures, bring an assistant and a chair to the session. Pad bedrails with seizure pads or blankets. Do not leave the patient unattended out of bed if seizures are frequent.

  • Environmental triggers: Avoid flashing lights — even flickering fluorescent lights can induce a seizure. Illness, fever, low blood sugar, stress, lack of sleep, and fatigue increase seizure susceptibility.

  • Document seizure precautions in the evaluation. New-onset seizures may indicate a decline in medical status — notify the physician if a new seizure occurs during or after your session. Resume orders should be obtained for any new-onset seizure before continuing therapy.

  • Post-ictal considerations: Todd's paralysis (transient focal weakness following a seizure) can mimic a new stroke or neurological decline. Do not interpret post-ictal deficits as a permanent change — document the timeline and communicate clearly to the team.

⚠ Seizure Response — Therapy Guidelines

(Hamby, 2024)

During a Seizure

  • Lay the patient down immediately. Use the floor if necessary. If there is enough warning, get the patient back to bed, flatten the bed, and put up padded bedrails. Protect the head with something soft and flat.
  • Turn the patient onto their side.
  • Clear the area of hazards (walkers, tables, chairs, IV poles).
  • Do not restrain the patient — force can cause muscle strain, fractures, or shoulder dislocation.
  • Do not put anything in the patient's mouth.
  • Press the call light and call for help. Do not leave the patient alone.
  • Loosen tight clothing around the neck. Remove glasses, necklaces. Do not remove any medically necessary neck collar.
  • Time the seizure if possible.
  • Be aware that incontinence can occur — provide privacy if possible.
  • Do not initiate CPR unless there is no pulse or respiration.

After a Seizure

  • Check for injuries and treat as necessary (can range from bruising to fracture or head injury).
  • Speak quietly and calmly; reorient the patient. Cover them to keep warm and protect from embarrassment.
  • Do not give anything to eat or drink until the patient is fully awake and alert.
  • Notify nursing immediately. Notify the physician if the seizure lasted >5 minutes or is a new-onset seizure.
  • Document the seizure: onset time, duration, type of movements observed, postictal state (see note on Todd's paralysis above), and patient status at end of session.
  • Do not resume therapy during the same session unless cleared by the medical team.

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References

Betjemann, J. P., & Lowenstein, D. H. (2015). Status epilepticus in adults. The Lancet Neurology, 14(6), 615–624. https://doi.org/10.1016/S1474-4422(15)00042-3

Hamby, J. R. (2024). The nervous system, part 2: Neurodegenerative diseases and other conditions. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (3rd ed., pp. 449–496). AOTA Press.

Trinka, E., Cock, H., Hesdorffer, D., Rossetti, A. O., Scheffer, I. E., Shinnar, S., Shorvon, S., & Lowenstein, D. H. (2015). A definition and classification of status epilepticus — Report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia, 56(10), 1515–1523. https://doi.org/10.1111/epi.13121