Status Epilepticus: A Prolonged Seizure Case Approach

The case: a seizure that will not stop

In our teaching scenario, a man in his thirties with known epilepsy is found shaking on the kitchen floor by his partner. She notes the time. Most seizures settle within one to two minutes, but this one continues. His arms and legs jerk, his breathing sounds noisy, and he does not respond. At the five-minute mark he is still fitting. His partner phones 999 and follows the call handler's advice: she does not restrain him, moves sharp objects away, and cushions his head. A seizure lasting five minutes or longer, or repeated seizures without recovery in between, is called status epilepticus and needs urgent help.

Why time matters so much

A brief seizure is usually harmless, but a prolonged one is different. When electrical activity in the brain does not switch off, brain cells work far too hard and can become injured. Breathing may become irregular, oxygen levels can fall, and body temperature and blood sugar may swing. The longer a seizure runs, the harder it becomes to stop, because the brain's natural braking chemicals get used up. This is why emergency teams act quickly and why the five-minute rule exists. Early treatment gives the best chance of the seizure ending safely and reduces the risk of lasting harm. Every minute genuinely counts, which is why bystanders should note the start time if they can.

What first aid looks like

Good seizure first aid is simple and calm. Stay with the person and time the seizure. Cushion their head, loosen anything tight around the neck, and clear away hard or sharp things. Do not hold them down and never put anything in their mouth; they cannot swallow their tongue, and objects can break teeth or block the airway. Once the jerking stops, gently roll them onto their side into the recovery position to keep the airway clear. Call 999 if the seizure lasts more than five minutes, if another follows quickly, if the person is injured, is not their usual self afterwards, or if it is their first ever seizure. Reassure them as they recover.

In the ambulance and hospital

Paramedics and hospital staff follow a stepwise plan. Their first priorities are the airway, breathing and circulation, giving oxygen and checking blood sugar, because a low sugar level can cause seizures and is quickly treatable. Emergency medicines are given to stop the seizure, usually starting with a first-line drug and moving to a second-line drug if the fitting continues. If seizures still do not settle, the person may be taken to intensive care and placed under anaesthetic to rest the brain. Throughout, the team looks for a cause, such as a missed epilepsy medicine, infection, low sodium, alcohol, or a problem inside the brain. Doses are always chosen by clinicians for the individual.

Recovery, causes and prevention

After a prolonged seizure, people are often drowsy, confused or sore for several hours; this is normal and settles. The team investigates why it happened. In someone with epilepsy, common triggers include missed medication, poor sleep, illness, alcohol, and stress. For a first seizure, tests may include blood checks, brain scans and an EEG, which records brain activity. Prevention focuses on taking epilepsy medicines exactly as prescribed, keeping a seizure diary, avoiding known triggers, and having a personal emergency plan agreed with the epilepsy team. Some people are prescribed rescue medication for use at home by trained family members. Anyone with epilepsy should have regular reviews and know when their driving and work may be affected.