Clinical Pathway for Evaluation/Treatment of
Infants and Children with Status Epilepticus
- ABCDE, IV Access, neurologic assessment, oxygen, CR monitor
- POC Glucose
- Labs as indicated
- Review maintenance anti-seizure medication (ASM) regimen
- Rapid administration of benzodiazepines and anti-seizure medications is essential to stop seizure as quickly as possible at each step, anticipate, prepare next medication
Seizure continues 3–5 min
1st Benzodiazepine 5-10 min
Administer 1st Benzodiazepine
Lorazepam 0.1 mg/kg IV, Max 4 mg
Lorazepam 0.1 mg/kg IV, Max 4 mg
No IV: Midazolam 0.3 mg/kg IN (or buccal), Max 10 mg
Seizure continues 3–5 min
Administer 2nd Benzodiazepine
Lorazepam 0.1 mg/kg, Max 4 mg
Lorazepam 0.1 mg/kg, Max 4 mg
Seizure continues 3–5 min
1st ASM 10–20 min
Administer 1st ASM
Levetiracetam 60 mg/kg IV, Max 4500 mg
Levetiracetam 60 mg/kg IV, Max 4500 mg
- Maintenance Levetiracetam > 80 mg/kg/day
- 1st ASM fosphenytoin 20 mg PE/kg IV, Max 1500 mg PE
- 2nd ASM valproate 40 mg/kg, Max 3,000 mg
- POLG: Valproate contraindicated
Seizure continues > 10 min
2nd ASM 20–30 min
Administer 2nd ASM
Fosphenytoin 20 mg PE/kg IV, Max 1500 mg PE
Age < 1 mo: Consider phenobarbital 20 mg/kg IV, Max 2000 mg
Fosphenytoin 20 mg PE/kg IV, Max 1500 mg PE
Age < 1 mo: Consider phenobarbital 20 mg/kg IV, Max 2000 mg
Seizure continues > 10 min
- Consult Neurology, recommends 3rd ASM
- Notify PICU, Tier as indicated
- Assess need for advanced airway
- Review differential diagnosis, treat underlying cause
- Initiate EEG Monitoring
- Consult Neurology
- ICU Anesthetic Infusions: Midazolam, Ketamine, Pentobarbital
- Additional Therapies for RSE
Evidence
- Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society
- Guidelines for the Evaluation and Management of Status Epilepticus
- Status Epilepticus and Refractory Status Epilepticus Management
- Generalized Convulsive Status Epilepticus in Adults and Children: Treatment Guidelines and Protocols
- Practice Parameter: Diagnostic Assessment of the Child With Status Epilepticus (an evidence-based review)
- Time From Convulsive Status Epilepticus Onset to Anticonvulsant Administration in Children