| Timeline
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General Considerations
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Seizure Treatment
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| 0-5 minutes
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- 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
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- 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)
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| 5-10 minutes
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- Give antibiotics if concern for sepsis or meningitis
- POC electrolytes, if available
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- Benzodiazepine: second dose
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| 10-15 minutes
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- 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
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- 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)¥
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| 15-30 minutes
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- 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)
- 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)
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| >30 minutes
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- 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)
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^May be ineffective for toxin-induced seizures and contraindicated in cocaine toxicity
