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Initial management of pediatric status epilepticus

Timeline General Considerations Seizure Treatment
0-5 minutes
  • Supportive care
  • Establish IV/IO access
  • Check blood glucose
  • If fever, acetaminophen 15 mg/kg rectally
  • Benzodiazepine: first dose
    • IV/IO access establised
      • Lorazepam 0.1 mg/kg IV or IO (max = 4 mg), OR
      • Diazepam 0.2 mg/kg IV or IO, (max = 8 mg)
    • IV or IO access not achieved within 3 minutes:
      • Buccal midazolam 0.2 mg/kg (max = 10 mg), OR
      • IM midazolam 0.1 to 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 signs of sepsis or meningitis
  • POC electrolytes, if available
  • Benzodiazepine: second dose
10-15 minutes
  • Antiepileptic: first therapy
15-30 minutes
  • Consider intubation, if not already performed
  • Pediatric neurology consultation
  • Antiepileptic: second therapy
    • Fosphenytoin^ (if not already given) 20 mg PE per kg IV or IO, OR
    • Valproate (if not already given) 20 to 40 mg/kg IV or IO, OR
    • Phenobarbital (if not already given) 20 mg/kg IV or IO, (max = 1 g; 10 mg/kg if phenobarbital already given), OR
    • Levetiracetam (if not already given) 40 mg/kg IV or IO,
  • If isoniazid toxicity suspected, pyridoxine
    • Infants (<1 year): 100 mg IV or IO in
    • Otherwise 70 mg/kg IV or IO (max = 5 g)

^May be ineffective for toxin-induced seizures and contraindicated in cocaine toxicity