ED Pathway for Evaluation/Treatment of Children
with Status Epilepticus
0-5 min
arrow
Triage
arrow
  • MD/CRNP/RN Immediate Management
  • ABCDE, Oxygen, Monitors
  • IV access, Glucose POC
  • Brief H&P
  • Initial Laboratory Studies
    • CBC, CMP, Mg, Phos
      HCG, tox screen, anticonvulsant levels as indicated
Rapid administration of anti-seizure medications is necessary to stop the seizure. Anticipation/preparation of the next agent is essential.
arrow
5-10 min
1st Medication
Prepare / Administer 1st Medication
Administer 1st Lorazepam 0.1 mg/kg IV, max 4 mg
arrow
Choosing 2nd/3rd Medication:
  • If on Levetiracetam < 80 mg/kg/day:
    • 2nd medication Levetiracetam
    • 3rd medication Phenytoin
  • If on Levetiracetam > 80 mg/kg/day:
    • 2nd medication Phenytoin
    • 3rd medication Valproate
  • If on Phenytoin:
    • 2nd medication Levetiracetam
    • 3rd medication Valproate

If patient received Benzodiazepine prior to arrival, consider moving to 2nd agent after 1st Lorazepam dose.

arrow
PICU Tier 2

ED Attending calls PICU Attending directly
Preparation for EEG monitoring, ICU care

Neurology Consult

Recommendations for 4th agent, as needed

Reassess 5 minutes
If seizure continues, proceed
If no IV access in 5 minutes,
consider buccal midazolam
Administer 2nd Lorazepam 0.1 mg/kg IV, Max 4 mg
and Prepare 2nd Medication
Levetiracetam:50 mg/kg, max 2500 mg or
Phenytoin:25 mg/kg
Reassess 5 minutes
If seizure continues, proceed
arrow
Administer 2nd Medication
15-30 min
2nd Medication
Reassess 5 minutes
If seizure continues 5 min into
infusion of 2nd medication, proceed
arrow
Refractory Status Epilepticus
Prepare 3rd Medication
Phenytoin:25 mg/kg or
Valproate:40 mg/kg
Notify PICU and Neurology
Reassess 5 minutes
If seizure continues, proceed
arrow
Administer 3rd Medication
30-45 min
3rd Medication
If still seizing after 3rd
medication administered, follow
Neurology and PICU recommendations.
arrow
Posted: November 2008
Revised: October 2011, August 2011, August 2015
Authors: N. Abend, MD, A. Topjian, MD, R. Ichord, MD, J. Fein, MD, J. Hewlett, Pharm D, K. Lourie, RN, K. Young, RN, J. Lavelle MD, D. Dlugos, MD