Emergency · Workflow hub · Feline

Status epilepticus hub — feline

Stepwise protocol for feline status epilepticus. Enter patient weight to generate a dose sheet for each step of the escalation pathway. ← Canine version

Check blood glucose first. Hypoglycemic seizures look identical to status. If BG < 60 mg/dL, give dextrose before benzodiazepines.
Treat the temperature. Hyperthermia from prolonged seizures kills neurons. Active cooling (alcohol on paws, fan, IV fluids at room temp) to 39.4°C / 103°F target. Stop cooling at 39.4 to avoid overshoot.
Phenobarbital is slow IV, not bolus. Rapid administration causes hypotension and respiratory depression. Give over 5–10 minutes.

Stepwise escalation

Step 1. Benzodiazepine bolus. Repeat up to 3 times, 5 min apart.

Step 2. If still seizing after 2–3 benzo doses: AED loading (levetiracetam preferred).

Step 3. Refractory status: anesthetic CRI (midazolam or propofol). Intubate.

Throughout. Glucose, temperature, IV access, electrolytes, airway.

Awaiting input

Enter a patient weight to see the result.

Reference

Status epilepticus escalation

Initial assessment (parallel to step 1)

Establish IV access (or IO if unable).
Check blood glucose. If < 60 mg/dL, treat hypoglycemia first.
Check temperature. Begin active cooling if > 40.5°C / 105°F.
Note seizure type and duration. Status = continuous seizure activity > 5 min OR ≥ 2 seizures without full recovery between.
If known epileptic on chronic AEDs, get serum levels but do not delay treatment.

Step 1 — first-line benzodiazepine

Midazolam 0.2 mg/kg IV/IM/IN is often preferred over diazepam in cats and is excellent intranasally when no IV access. Diazepam 0.5 mg/kg IV is also acceptable; the historical "diazepam-induced fulminant hepatic necrosis" warning in cats was specifically from oral repeated dosing, not acute IV bolus. Repeat up to 3 doses 5 minutes apart. If still seizing after 2–3 benzo doses, escalate.

Step 2 — AED loading

Levetiracetam 60 mg/kg IV slow bolus is the preferred loading dose; reduce to 30 mg/kg if there is significant cardiovascular concern. The Hardy 2012 RCT showed levetiracetam IV controlled status in 56% of dogs (extrapolated to cats; species-specific feline IV studies are limited but clinical use is well established) that had failed diazepam, with rapid onset and minimal cardiovascular effect. Begin maintenance at 20 mg/kg q8h IV/PO.

Phenobarbital 4–6 mg/kg IV slow bolus over 5–10 minutes is the alternative. Repeat every 20 minutes to a total maximum of 16–24 mg/kg in the first 24 hours. The maintenance dose follows at 2.5–3 mg/kg PO q12h once stabilized.

Step 3 — refractory / anesthetic CRI

If seizures continue despite step 1 and 2, the patient needs general anesthesia. Intubate. Midazolam CRI 0.1–0.5 mg/kg/hr is first choice in most patients; propofol CRI 0.1–0.25 mg/kg/min is the alternative or adjunct, with the caveat that propofol CRI duration should be limited to roughly 48 hours.

Ketamine bolus 2 mg/kg IV (followed by CRI 2–10 µg/kg/min) is a last-resort option. Avoid in cats with known HCM. Inhalant anesthesia is the final fallback.

Wean CRIs gradually after 24 hours seizure-free. Sudden discontinuation precipitates withdrawal seizures.

Throughout — supportive care

Maintenance IV crystalloids at 2–4 mL/kg/hr unless contraindicated.
Treat hyperthermia. Stop active cooling at 39.4°C / 103°F to avoid overshoot.
Monitor BP, ECG, SpO₂. Hypotension is common with anesthetic CRIs.
Recheck glucose, electrolytes, lactate every 2–4 hours.
Assess for and treat the underlying cause: toxin exposure, hepatic encephalopathy, intracranial disease, hypoglycemia, hypocalcemia.