Side Menu Card

EEG Monitoring Clinical Pathway, PICU, N/IICU and CICU – Benzodiazepines and Anti-Seizure Medications

EEG Monitoring Clinical Pathway — PICU, N/IICU, and CICU

Benzodiazepines and Anti-Seizure Medications

Consider the following medications for the Seizure Action Plan.

See Status Epilepticus Clinical Pathway for guidance on management.

Medication Management Role Dose (mg/kg) Max Dose (mg) Considerations
Lorazepam
  • Initial treatment
  • 0.1 mg/kg IV
  • 4 mg
  • May repeat dose in 5 mins if seizure persists
  • Consider other options if recently received benzodiazepines or a benzodiazepine drip
Anti-Seizure Medications
Levetiracetam
  • 1st Line:
    Non-neonates
 60 mg/kg IV
  • 4,500 mg
  • ED, ICUs, 9S
    • Local Pyxis
  • Administration
    • Infuse IV over 10 mins
Phenobarbital
  • 1st Line:
    Neonates
  • 20 mg/kg IV
  • Followed by an additional IV 10-20 mg/kg if indicated
  • Single Dose Max
    2,000 mg
  • ED, ICUs, 9S
  • Doses ≤ 500 mg
    • Local Pyxis, dilute to 10 mg/mL
  • Doses > 500 mg
    • Pharmacy, no additional dilution required
  • Administration
    • Maximum concentration:
      • 10 mg/mL
    • Maximum infusion rate:
      • Infants/children: 1 mg/kg/min up to 30 mg/min
      • Adults: 60 mg/min
  • Consider alternatives if there are concerns for:
    • Hypotension or respiratory depression
Fosphenytoin
  • Alternative:
    Neonates and
    non-neonates
  • IV/IM 20 mg PE/kg
  • Followed by an additional IV 10 mg PE/kg if indicated
  • PE = phenytoin equivalents
  • Single Dose Max
    1,500 mg PE
  • If an additional dose is given:
    Max 1,500 mg PE
  • ED
    • Dose ≤ 1,000 mg PE
      • Local Pyxis med refrigerator
    • Dose > 1,000 mg PE
      • Main ED Team: Preparation by ED Pharmacist
      • Resuscitation Room: Preparation by ED Pharmacist or Resuscitation Med RN
        • Call ED Pharmacist to bring vials to the Resuscitation Bay
    • Utilize 2 syringe method to prepare doses > 1,000 mg PE
      • Syringe 1 dilute to 25 mg PE/mL up to 1,000 mg PE
      • Syringe 2 dilute to 25 mg PE/mL up to 500 mg PE
      • Administer syringe 1 + 2 to complete dose up to 1,500 mg PE
  • PICU, N/IICU, 9S
    • Dose ≤ 1,000 mg PE
      • Local Pyxis, dilute to 25 mg PE/mL
    • Dose > 1,000 mg PE
      • Pharmacy, no additional dilution required
  • Other Locations Including CICU
    • Pharmacy
  • Administration
    • Maximum IV concentration:
      • 25 mg PE/mL
    • Maximum IV infusion rate:
      • Infants/children: 2 mg PE/kg/min
      • Adults: 150 mg PE/kg/min
    • Maximum IM concentration:
      • 50 mg PE/mL
    • Consider alternatives if:
      concern for cardiac dysfunction
    • Additional Dose
      • 10 mg PE/kg/dose IV or IM
Valproate Sodium
  • Alternative:
    non-neonates
  • 1st Line:
    Generalized epilepsy
  • IV 40 mg/kg
  • Followed by an additional IV 20 mg/kg
    if indicated
  • Single Dose Max
    3,000 mg
  • All doses from pharmacy
  • Administration
    • Maximum IV infusion rate:
      • 5 mg/kg/min
  • Consider alternatives for:
    • Age < 2 yrs, hepatic dysfunction, pancreatitis, thrombocytopenia or metabolic disease
  • Use first line for:
    • Known generalized epilepsy diagnoses including childhood absence epilepsy, juvenile absence epilepsy, and juvenile myoclonic epilepsy
  • Additional Dose
    • 20 mg/kg/dose

Anti-Seizure Medication: Other Considerations

Condition Recommendations
Hepatic dysfunction
  • Consider levetiracetam
  • Avoid valproate
Cardiac dysfunction
  • Consider levetiracetam
  • Avoid fosphenytoin
  • Respiratory depression
  • Hypotension
  • Consider levetiracetam or valproate
  • Avoid phenobarbital
  • Hypoalbuminemia
  • Polypharmacy with hepatic metabolized medications
  • Consider levetiracetam
  • Consider calculating adjusted phenytoin levels
  • When available, consider sending drug levels
  • Thrombocytopenia
  • Metabolic disease
  • Encephalopathy of unknown etiology
  • < 2 yrs of age
  • Pancreatitis
 Avoid valproate
No IV access
  • Consider
    • Fosphenytoin IM
      • 20 mg PE/kg, max dose: 1,500 mg PE
    • Diazepam PR
      • 0.5 mg/kg, max dose: 20 mg
    • Midazolam buccal/intranasal
      • 0.3 mg/kg, 5 mg/ml concentration, max dose: 10 mg
      • Atomizer and dead space adjustment needed for
        intranasal administration