Emergency Department Clinical Pathway for
Evaluation/Treatment of Children with Status Epilepticus

0-5 min
  • 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.
5-10 min
1st Medication
Prepare / Administer 1st Lorazepam
0.1 mg/kg IV, max 4 mg
Prepare 2nd Lorazepam
0.1 mg/kg IV, max 4 mg
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 a benzodiazepine prior to arrival, consider advancing to 2nd agent after 1st lorazepam dose.

PICU Tier 2

ED Attending calls PICU Attending directly.
Preparation for EEG monitoring and ICU care.

Neurology Consult

Recommendations for 4th medication, as needed.

Reassess in 5 minutes
If no IV access in 5 minutes,
consider buccal midazolam
Administer 2nd Lorazepam
Prepare 2nd Medication
Levetiracetam: 50 mg/kg, max 2500 mg or
Phenytoin: 25 mg/kg
Reassess in 5 minutes
Administer 2nd Medication
10-20 min
2nd Medication
Reassess 5 minutes into
2nd medication infusion
Prepare 3rd Medication
Phenytoin: 25 mg/kg or
Valproate: 40 mg/kg or
Levetiracetam: 50 mg/kg

Notify PICU and Neurology

Reassess at end of 2nd medication infusion
Administer 3rd Medication
20-40 min
3rd Medication
Primary Team Management with Neurology consultation
Posted: November 2008
Revised: October 2011, August 2011, July 2015, May 2016, June 2016, February 2017, April 2019
Authors: N. Abend, MD; A. Topjian, MD; R. Ichord, MD; J. Fein, MD; K. Lourie, RN; K. Young, RN;
J. Lavelle MD; D. Dlugos, MD
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