Emergency Department Clinical Pathway for
Evaluation/Treatment of Children with Status Epilepticus
0-5 min
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
- CBC, CMP, Mg, Phos
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
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
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)
(IV or no IV)
PICU Tier 2
ED Attending calls PICU Attending directly.
Preparation for EEG monitoring and ICU care.
Recommendations for 4th medication, as needed.
Reassess in 5 minutes
If no IV access in 5 minutes,
consider buccal midazolam
consider buccal midazolam
Administer 2nd Lorazepam
Prepare 2nd Medication
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
2nd Medication
Reassess 5 minutes into
2nd medication infusion
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
3rd Medication
Primary Team Management with Neurology consultation
PICU Management for Refractory Status Epilepticus
Continuous anesthetic infusions:Midazolam | Pentobarbital | Ketamine
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
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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