Status Epilepticus
Seizures (Convulsions/ Fits)
G41.0-2; G41.8-9
DESCRIPTION
In status epilepticus, the seizures do not stop, or they occur repeatedly in close succession with impaired consciousness between seizures. Status epilepticus may be ‘convulsive’ (associated with prominent motor symptoms) or ‘nonconvulsive’ (i.e., without prominent motor symptoms).
Convulsive status epilepticus:
Convulsive status epilepticus is defined as ≥ 5 minutes of either:
- a continuous generalised or bilateral tonic clonic seizure, or
- two or more discrete generalised, or bilateral tonic clonic seizures with incomplete recovery of consciousness between the seizures.
Convulsive status epilepticus is a medical emergency. There are two critical time points:
- Time point 1: 5 minutes from the onset of the initial epileptic seizure (i.e., at the point of diagnosis). Immediate treatment is needed to prevent ongoing epileptic seizure activity.
- Time point 2: 30 minutes of epileptic seizure activity, timed from the onset of the seizure. After 30 minutes of seizure activity, irreversible brain damage related to hypoxia, acidosis, depletion of local energy stores, cerebral oedema and structural damage, is likely to occur.
Complications of convulsive status epilepticus include:
- hyperpyrexia
- disturbances of blood glucose
- respiratory depression
- renal failure
- cerebral oedema
- acidosis
- blood pressure disturbances
- inappropriate antidiuretic hormone (ADH) secretion
- hypoxic ischaemic damage to brain, myocardium and muscles.
Non-convulsive status epilepticus:
Non-convulsive status epilepticus refers to abnormally prolonged or rapidly recurring epileptic seizures with impaired consciousness but no major motor symptoms (e.g., focal seizures with autonomic, sensory or perceptual manifestations or absence seizures). The presentation is often subtle, and the seizures may not be recognised. Diagnosis is confirmed on EEG. Treat as for convulsive status epilepticus below; see Epileptic seizures and status epilepticus in children <13 years and Epileptic seizures and status epilepticus in adolescents (13-18 years) and adults. Ensure that underlying causes are identified and managed.
Causes of epileptic seizures and status epilepticus
With every epileptic seizure, the underlying cause of the seizure must be determined and treated, including in people with epilepsy.
Important causes of epileptic seizures that must be considered include:
- Infectious conditions e.g., meningitis or encephalitis
- Encephalopathy e.g., hypertensive encephalopathy or cerebral hypoxia
- Metabolic conditions e.g., hypoglycaemia, hypo- or hypernatraemia, hypocalcaemia
- Brain lesions e.g., brain tumours, stroke and post-stroke sequelae, trauma and post-traumatic sequelae
- Substance withdrawal e.g., alcohol or benzodiazepines
- Substance intoxication e.g., cocaine or amphetamines
- Poisoning or toxin ingestion (accidental or intentional as in an overdose) e.g. isoniazid
- Other neurological (e.g., cerebral palsy) or neurodegenerative (e.g., Alzheimer’s dementia) conditions
- Epilepsies e.g., breakthrough seizures, treatment non-adherence, recent changes to antiseizure medicine (ASM), antiseizure medication toxicity.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4_Version 1.0_26 May 2025
Chapter 15: Central Nervous System Conditions_15.5 Status Epilepticus