Status Epilepticus Clinical Pathway — Emergency | Children's Hospital of Philadelphia

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

0-5 min

Status Epilepticus

Triage

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.

Anti-Seizure Medications
(IV or no IV)

Further Diagnostic Testing

PICU Tier 2

ED Attending calls PICU Attending directly
Preparation for EEG monitoring, 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

PICU Management for Refractory Status Epilepticus

Midazolam Titration

Posted: November 2008
Revised: October 2011, August 2011, July 2015, May 2016, June 2016, February 2017
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

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.