Seizure and Status Epilepticus: The Five-Minute Rule and the Benzodiazepine Ladder

Status epilepticus is the acute medicine scenario with the clearest clock. NICE NG217 makes convulsive status epilepticus a seizure of 5 minutes or more, and everything after that is a timed ladder you can say out loud.

Key takeaways

• NICE NG217, Epilepsies in children, young people and adults, was published on 27 April 2022 and last updated on 5 August 2026.
• Recommendation 7.1.1 says to provide resuscitation and immediate emergency treatment for convulsive status epilepticus, which it defines as seizures lasting 5 minutes or more.
• Recommendation 7.1.3 says to give a benzodiazepine, buccal midazolam or rectal diazepam, immediately as first-line treatment in the community, or to use intravenous lorazepam if intravenous access and resuscitation facilities are immediately available.
• Recommendation 7.1.8 says to give a second dose of benzodiazepine if the seizure does not stop within 5 to 10 minutes of the first dose.
• Recommendation 7.1.9 says that if status epilepticus does not respond to 2 doses of a benzodiazepine, give intravenous levetiracetam, phenytoin or sodium valproate, and that levetiracetam may be quicker to administer with fewer adverse effects.
• NG217 names the drugs but states no doses, so quote your local status epilepticus protocol and the BNF rather than inventing a figure.

How do you recognise status epilepticus?

You recognise status epilepticus by the clock. NICE NG217 treats a convulsive seizure lasting 5 minutes or more as convulsive status epilepticus requiring resuscitation and immediate emergency treatment.

NG217 records why the definition changed. The International League Against Epilepsy proposed a new definition meaning that all seizures lasting longer than 5 minutes constitute status epilepticus, replacing the older 30-minute figure.

• Recommendation 7.2.1 asks you to manage repeated or cluster seizures, typically 3 or more self-terminating seizures in 24 hours, as a medical emergency.
• Recommendation 7.3.1 asks you to manage a prolonged convulsive seizure, defined as any convulsive seizure continuing more than 2 minutes longer than a person's usual seizure, as a medical emergency.
• Recommendation 7.1.6 warns that non-epileptic seizures, also called dissociative seizures, can be similar in presentation to convulsive status epilepticus.

Say the check that costs nothing. Recommendation 7.1.4 asks you to be aware of underlying causes including hypoglycaemia, eclampsia and alcohol withdrawal, which may need additional medication.

What do you do in the first hour of status epilepticus?

In the first minutes of status epilepticus you resuscitate and give a benzodiazepine at the same time. NICE NG217 recommendation 7.1.1 asks for resuscitation and immediate emergency treatment together, not in sequence.

• Airway with an adjunct and high-flow oxygen, with anaesthetic help called early.
• A capillary glucose immediately, because recommendation 7.1.4 names hypoglycaemia as an underlying cause.
• Intravenous access, bloods including glucose, electrolytes, calcium, magnesium, a blood gas and antiseizure medication levels where relevant.
• Recommendation 7.1.2 asks you to follow the person's individualised emergency management plan if it is immediately available.
• Recommendation 7.1.3 otherwise gives buccal midazolam or rectal diazepam in the community, or intravenous lorazepam where access and resuscitation facilities are immediately available.

NG217 explains the choice rather than leaving it to be guessed. The committee agreed that intravenous lorazepam is routinely given in hospitals and should be the first choice there because of its rapid action and less respiratory depression and sedation.

What is the named time interval between doses?

The named interval in status epilepticus is 5 to 10 minutes. Recommendation 7.1.8 asks for a second dose of benzodiazepine if the seizure does not stop within 5 to 10 minutes of the first dose.

Recommendation 7.1.7 sits alongside it. If convulsive status epilepticus does not respond to the first dose of benzodiazepine, call the emergency services in the community, or seek expert guidance in hospital.

Two doses is the ceiling. After two doses of a benzodiazepine, the pathway moves to second-line intravenous treatment, and a third benzodiazepine dose is not what NG217 recommends.

Say why the ceiling exists. Repeated benzodiazepine dosing in status epilepticus buys diminishing seizure control at rising cost in respiratory depression and airway compromise.

What is the definitive management of status epilepticus?

Definitive management of status epilepticus is second-line intravenous antiseizure medication, then third-line treatment under expert guidance, alongside treatment of the cause.

• Recommendation 7.1.9 offers intravenous levetiracetam, phenytoin or sodium valproate, taking into account that levetiracetam may be quicker to administer and have fewer adverse effects than the alternatives.
• The same recommendation asks you to follow the Medicines and Healthcare products Regulatory Agency safety measures and precautionary advice for sodium valproate, which NICE reinforced in a January 2025 update.
• Recommendation 7.1.10 says that if status epilepticus does not respond to a second-line treatment, consider trying an alternative second-line option under expert guidance.
• Recommendation 7.1.11 gives the third-line options under expert guidance as phenobarbital or general anaesthesia.
• Recommendation 7.1.12 asks you to agree an emergency management plan afterwards if the person does not already have one and there is concern status epilepticus may recur.

Recommendation 7.1.5 adds the cause candidates forget. Be alert to non-adherence to antiseizure medication, which can itself be the reason a known epileptic patient is in status.

When do you escalate a patient in status epilepticus?

You escalate status epilepticus early and by name. Recommendation 7.1.7 asks you to seek expert guidance in hospital as soon as the first dose of benzodiazepine has failed, not after the second.

• Anaesthetics or critical care at the point you are giving a second benzodiazepine dose, because the airway is the thing that fails next.
• Neurology for the second-line choice and for what happens if it does not work.
• Obstetrics immediately in a pregnant patient, because recommendation 7.1.4 names eclampsia as an underlying cause with its own treatment.
• Critical care for third-line treatment, since general anaesthesia is one of the two third-line options in recommendation 7.1.11.

Say plainly that you would put out the call rather than wait to see whether the next dose worked. Escalating a patient in status epilepticus early is never the criticised decision.

How do you hand over a patient after status epilepticus in one minute?

Hand over status epilepticus with the timeline. The receiving team needs to know how long the patient seized, what was given, at what time, and what the airway plan is now.

Use SBAR and put the doses and times in the background, the current conscious level in the assessment, and the airway plan in the recommendation.

A worked version, said aloud: this is a 31-year-old woman with known epilepsy who seized for 12 minutes. She has had two doses of lorazepam and is loading with levetiracetam. She is post-ictal with a GCS of 10. I need anaesthetics at the bedside and a repeat glucose.

What does the panel listen for in a status epilepticus answer?

The panel listens for whether your status epilepticus answer has times attached. The ladder is only useful if you say when each rung happens and who you call at each one.

• That you give the 5-minute definition and know it replaced the 30-minute one.
• That you check a glucose in the first minute.
• That you stop at two benzodiazepine doses and move to second-line treatment.
• That you name levetiracetam, phenytoin and sodium valproate as the second-line options, with the valproate safety caveat.
• That you say NG217 does not give doses and you would use the local protocol, rather than inventing one.
• That you look for a cause while you treat, including non-adherence, alcohol withdrawal, hypoglycaemia and eclampsia.

What are the common mistakes in a status epilepticus station?

The commonest mistake in a status epilepticus station is waiting. Candidates who describe observing a convulsing patient for twenty minutes have failed the station on the first recommendation.

• Giving a third and fourth dose of benzodiazepine instead of moving to second-line treatment.
• Never mentioning the airway, when respiratory depression is the predictable consequence of what you are giving.
• Forgetting the glucose, which is named in NG217 as an underlying cause.
• Missing pregnancy, and so missing eclampsia.
• Treating the seizure and never asking why, when recommendation 7.1.5 names non-adherence as a cause of status epilepticus.
• Quoting a dose with confidence. NG217 states none, and a wrong dose said firmly is worse than saying you would use the local protocol.

How this comes up at the IMT interview

At the IMT interview, a seizure or status epilepticus scenario sits in station 2, a clinical scenario of up to ten minutes on investigations, diagnosis and management, then a one-minute handover of the same patient.

It can also turn into a first-seizure question. NICE NG217 recommendation 1.1.1 asks for an urgent referral, for an appointment within 2 weeks, after a first suspected seizure, and recommendation 1.2.2 asks for a 12-lead electrocardiogram to identify cardiac conditions that mimic a seizure.

internalmedicineinterview's bank of 361 IMT questions across 56 scenarios covers acute medicine scenarios like this with model answers and AI-marked spoken practice, so you can hear whether your timings held.