Status Epilepticus Clinical Pathway — ED, Inpatient and ICU

Clinical Pathway for Evaluation/Treatment of
Infants and Children > 2 months with Status Epilepticus

Goals and Metrics
0-5 min
Status Epilepticus
ED 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 medication 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
Reassess in 5 minutes
If no IV access, consider midazolam
Buccal
IM 		0.3 mg/kg
0.2 mg/kg
Choosing 2nd/3rd Medication:
  • If on Levetiracetam < 80 mg/kg/day:
    • 2nd medication Levetiracetam
    • 3rd medication Fosphenytoin
  • If on Levetiracetam > 80 mg/kg/day:
    • 2nd medication Fosphenytoin
    • 3rd medication Valproate
  • If on Phenytoin:
    • 2nd medication Levetiracetam
    • 3rd medication Valproate
Anti-Seizure Medications
  • Route
  • Loading and MAX Doses
  • Concentration, infusion rate
  • Availability
PICU Tier 2

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

Neurology Consult

Recommendations for 4th medication,
as needed.

Administer 2nd Lorazepam
Prepare 2nd Medication
Levetiracetam: 60 mg/kg or
Fosphenytoin: 20 mg PE/kg
Reassess in 5 minutes
Administer 2nd Medication
10-20 min
2nd Medication
Reassess 5 minutes into
2nd medication infusion
Prepare 3rd Medication
Fosphenytoin: 20 mg PE/kg or
Valproate: 40 mg/kg or
Levetiracetam: 60 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

Continuous anesthetic infusions:
Midazolam | Pentobarbital | Ketamine
Posted: November 2008
Revised: November 2024
Authors: N. Abend, MD; A. Topjian, MD; R. Ichord, MD; K. Resendiz Trujano, Pharm D.; J. Fein, MD; K. Lourie, RN; K. Young, RN;
J. Lavelle, MD; D. Dlugos, MD;