View source for Template:Initial management of pediatric status epilepticus/en

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===Initial management of [[Special:MyLanguage/pediatric status epilepticus|pediatric status epilepticus]]===

{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Timeline'''
| align="center" style="background:#f0f0f0;"|'''General Considerations'''
| align="center" style="background:#f0f0f0;"|'''Seizure Treatment'''
|-
| 0-5 minutes
||
*Supportive care 
** ABC's
** Maintain airway; suction, jaw thrust
** Provide [[Special:MyLanguage/O2|O2]] via positive pressure ventilation with BVM/Mapleson
***Likely apneic/hypoventilating/hypercapneic
***Only apply CPAP or a non-rebreather if patient stops seizing and has adequate chest rise
*Establish IV/[[Special:MyLanguage/IO|IO]] access 
*Check blood glucose 
*If fever, [[Special:MyLanguage/acetaminophen|acetaminophen]] 15 mg/kg rectally
||
*'''Benzodiazepine: first dose''' 
**IV/IO access established 
***[[Special:MyLanguage/Lorazepam|Lorazepam]] 0.1 mg/kg IV (max 4 mg) if IV/IO access, OR 
***[[Special:MyLanguage/Diazepam|Diazepam]] 0.2 mg/kg IM (max 10 mg) if no access 
**IV or IO access not achieved within 3 minutes: 
***Buccal [[Special:MyLanguage/midazolam|midazolam]] 0.2 mg/kg (max 10 mg), OR 
***IM  [[Special:MyLanguage/midazolam|midazolam]] 0.2 mg/kg (max 10 mg), OR 
***Rectal [[Special:MyLanguage/diazepam|diazepam]] (Diastat gel or injection solution given rectally) 0.5 mg/kg (max 20 mg) 
|-
| 5-10 minutes
||
*Give antibiotics if concern for [[Special:MyLanguage/sepsis|sepsis]] or [[Special:MyLanguage/meningitis|meningitis]] 
*POC electrolytes, if available
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*'''Benzodiazepine: second dose'''
|-
| 10-15 minutes
||
*All equally efficacious for status epilepticus
*Levetiracetam is preferred given quick administration, favorable side effect profile, and less drug interactions
*Do not combine Phenytoin and Fosphenytoin
||
*'''Antiepileptic: first therapy''' 
**[[Special:MyLanguage/Levetiracetam|Levetiracetam]] 60 mg/kg IV/IO (max 4500mg) over 5 min, OR 
**[[Special:MyLanguage/Fosphenytoin|Fosphenytoin]]^ 20 mg PE/kg IV/IO (max 1500mg) over 10 min, OR 
**[[Special:MyLanguage/Valproate|Valproate]]  40 mg/kg IV/IO (max 3000mg) over 10 min, OR 
**[[Special:MyLanguage/Phenobarbital|Phenobarbital]] 20 mg/kg IV/IO, (max 1 g) over 20 min, (expect respiratory depression with apnea)¥ 
|-
| 15-30 minutes
||
*Consider intubation, if not already performed
**Consider NG tube to decompress stomach prior to intubation
*Pediatric neurology consultation
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*'''Antiepileptic: second therapy''' (if medication not already given)
**[[Special:MyLanguage/Fosphenytoin|Fosphenytoin]]^ 20 mg PE/kg IV/IO (max 1500mg) over 10 min, OR 
**[[Special:MyLanguage/Valproate|Valproate]] 40 mg/kg IV/IO (max 3000mg) over 10 min, OR
**[[Special:MyLanguage/Phenobarbital|Phenobarbital]] 20 mg/kg IV/IO (max 1 g) over 20 min 
***10 mg/kg if phenobarbital already given, OR 
**[[Special:MyLanguage/Levetiracetam|Levetiracetam]] 60 mg/kg IV/IO (max 4500mg) over 5 min 
*If [[Special:MyLanguage/isoniazid toxicity|isoniazid toxicity]] suspected, [[Special:MyLanguage/pyridoxine|pyridoxine]] 
**Infants (<1 year): 100 mg IV or IO in 
**Otherwise 70 mg/kg IV or IO (max = 5 g)
|-
| >30 minutes
||
*Intubate patient, if not already performed
*Consult referral site / PICU for admission and continuous EEG
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*'''Antiepileptic: third therapy'''
**Midazolam 0.2mg/kg IV bolus (max 10mg), followed by 0.2mg/kg/hr (max 10mg/hr) infusion drip
**Increase infusion rate by 0.2mg/kg/hr (max 10mg/hr) every 10 minutes until burst suppression or max dose of 2mg/kg/hr (max 100mg/hr)
|}
^May be ineffective for toxin-induced seizures and contraindicated in [[Special:MyLanguage/cocaine toxicity|cocaine toxicity]]