Status Epilepticus - Clinical Pathway - Anti-Seizure Medications

Status Epilepticus Clinical Pathway — ED, Inpatient and ICU

Anti-seizure Medications

  • Rapid administration of anti-seizure medications is necessary to stop the seizure as soon as possible.
  • Levetiracetam is selected as the initial loading anti-seizure medication since it is readily available given it does not require dilution or refrigeration.
  • Anticipate the need for additional anti-seizure medications. Have the next medication ready for administration if the seizure continues 5 minutes after administration of the prior medication.

Process

  • Prepare two doses of lorazepam, and immediately administer the first dose.
    • If a benzodiazepine was given at home or by EMS, then order 2nd medication with the 1st lorazepam dose.
    • If IV access is not obtained or expected to be obtained within 5 minutes then, use non-IV access option while continuing efforts to obtain IV access.
      Buccal route is preferred, see options below
  • Reassess 3-5 minutes after the 1st dose of lorazepam.
  • If the seizure continues, then administer the 2nd dose of lorazepam and order the 2nd medication.
  • If the seizure continues after 5 minutes, then administer the 2nd medication.
  • Reassess 5 minutes into the infusion of the 2nd medication.
  • If the seizure continues, then prepare the 3rd medication, and notify PICU and Neurology, (Refractory Status Epilepticus)
  • Reassess 5 minutes.
  • If the seizure continues, then administer the 3rd medication.
  • If seizure continues, (regardless of time elapsed):
    • Administer 4th medication as per Neurology and PICU recommendation.
    • Expedite ICU transfer.
    • Support ABCs as clinically indicated.
1st Medication - Benzodiazepines
  Medication Route Dose (mg/kg) Max Dose (mg) Considerations
IV Access Lorazepam (Ativan®) IV 0.1 mg/kg 4 mg May repeat dose in 5 minutes if seizure persists.
NO IV Access Midazolam (Versed®)
(Preferred)		 Buccal 0.3 mg/kg 10 mg May repeat dose in 5 minutes if seizure persists.
Use IV midazolam 5 mg/mL concentration.
Diazepam (Valium®) Rectal 0.5 mg/kg 20 mg May repeat 0.25 mg/kg PR once in 10 minutes if seizure persists.

Max 10 mg for repeat dose.
Midazolam (Versed®) Intramuscular 0.2 mg/kg 10 mg May repeat dose in 5 minutes if seizure persists.
Midazolam (Versed®) Intranasal 0.3 mg/kg 10 mg May repeat dose 5 minutes if seizure persists.
Use IV midazolam 5 mg/mL concentration.

 

2nd and 3rd Medications
Medication Dose (mg/kg) Max Dose (mg) Considerations
Levetiracetam
(Keppra®)
  • < 2 mos 50 mg/kg
  • ≥ 2 mos 60 mg/kg
  • 4500 mg
  • Availability:
  • ED, ICU, 9S - Local Pyxis
  •  
  • Administration:
  • Infuse IV over 10 minutes.
Fosphenytoin
(Cerebryx®)
  • IV 20 mg PE/kg
  •  
  • Followed by an additional IV 10 mg PE/kg if indicated.
  •  
  • PE = phenytoin equivalents
  •  
  • May also administer IM
  • Single Dose Max 1500 mg PE
  •  
  • If an additional dose is given: Max 1500 mg PE/kg

Availability:

  • ED Only
  • Dose ≤ 1000 mg PE - Local Pyxis med refrigerator
  • Dose > 1000 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 > 1000 mg PE
    • Syringe 1 Dilute to 25 mg PE/mL up to 1000 mg PE
    • Syringe 2 Dilute to 25 mg PE/mL up to 500 mg PE
    • Administer Syringe 1 + 2 to complete dose up to 1500 mg PE
  •  
  • PICU, NICU, 9S
  • Dose ≤ 1000 mg PE - Local Pyxis, dilute to 25 mg PE/mL
  • Dose > 1000 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: 3 mg PE/kg/min
    • Adults: 50 mg PE/min
  • Maximum IM concentration:
    • 50 mg PE/mL
  •  
  • Additional dose:
  • 10 mg PE/kg/dose IV or IM
Phenytoin
(Dilantin®)
  • IV 20 mg/kg
  •  
  • Followed by an additional IV 10 mg/kg if indicated.
  • Single Dose Max 1500 mg
  •  
  • If an additional dose is given: Max 1500 mg
  • Availability:
  • ED, ICU, 9S - Local Pyxis
  • Other locations - Pharmacy
  •  
  • Administration:
  • Maximum concentration:
    • 5 mg/mL in NS only
  • Maximum infusion rate:
    • Infants/Children: 3 mg/kg/min
    • Adults: 50 mg/min
  •  
  • Consider alternatives if there are concerns for:
    • Poor IV access or cardiac arrhythmias.
  •  
  • Additional dose:
  • 10 mg/kg/dose
Valproate sodium
(Depacon®)
  • IV 40 mg/kg
  •  
  • Followed by an additional IV 20 mg/kg if indicated
  • Single Dose Max 3000 mg
  • Availability:
  • All doses from pharmacy
  •  
  • Administration:
  • Maximum IV infusion rate:
    • 5 mg/kg/min
  •  
  • Consider alternatives if there are concerns 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
Phenobarbital
  • 20 mg/kg
  •  
  • Followed by an additional IV 10-20 mg/kg if indicated.
  • Single Dose Max 2000 mg
  • Availability:
  • ED, ICU, 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
  •  
  • Additional dose:
  • 10-20 mg/kg/dose