Sandbox

Initial management of pediatric status epilepticus

Timeline	General Considerations	Seizure Treatment
0-5 minutes	Supportive care ABC's Maintain airway; suction, jaw thrust Provide 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/IO access Check blood glucose If fever, acetaminophen 15 mg/kg rectally	Benzodiazepine: first dose IV/IO access established Lorazepam 0.1 mg/kg IV (max 4 mg) if IV/IO access, OR Diazepam 0.2 mg/kg IM (max 10 mg) if no access IV or IO access not achieved within 3 minutes: Buccal midazolam 0.2 mg/kg (max 10 mg), OR IM midazolam 0.2 mg/kg (max 10 mg), OR Rectal diazepam (Diastat gel or injection solution given rectally) 0.5 mg/kg (max 20 mg)
5-10 minutes	Give antibiotics if concern for sepsis or meningitis POC electrolytes, if available	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 Levetiracetam 60 mg/kg IV/IO (max 4500mg) over 5 min, OR Fosphenytoin^ 20 mg PE/kg IV/IO (max 1500mg) over 10 min, OR Valproate 40 mg/kg IV/IO (max 3000mg) over 10 min, OR 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	Antiepileptic: second therapy (if medication not already given) Fosphenytoin^ 20 mg PE/kg IV/IO (max 1500mg) over 10 min, OR Valproate 40 mg/kg IV/IO (max 3000mg) over 10 min, OR Phenobarbital 20 mg/kg IV/IO (max 1 g) over 20 min 10 mg/kg if phenobarbital already given, OR Levetiracetam 60 mg/kg IV/IO (max 4500mg) over 5 min If isoniazid toxicity suspected, 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	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 cocaine toxicity