Status Epilepticus
- In children with acute central nervous system (CNS) infection
- As febrile seizures in an otherwise healthy child
- As a sign of progressive neurologic disease
- In a child with known epilepsy with inadequate blood levels and/or additional illness, metabolic causes (e.g., low glucose, hyponatremia, low calcium), structural causes such as a tumor or stroke, and toxins (e.g., alcohol).

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0-5 minutes -
- Confirm the diagnosis.
- Maintain airway by head positioning or oropharyngeal airway.
- Administer nasal or blow-by oxygen.
- Suction as needed.
- Obtain and monitor vital signs, use pulse oximetry and cardiac monitoriing as indicated.
- If the seizure has not abated within 4-5 minutes, establish an intravenous line.
- Obtain blood for laboratory determinations (glucose, serum chemistries, toxicology screen, culture, or anti-epileptic drug (AED) levels) as applicable.
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6-9 minutes -
- If hypoglycemic (or if rapid reagent strip for glucose testing is not available), administer 2 ml/kg of D25W or 5ml/kg D10W.
- If this is infant with no known seizure disorder, give pyridoxine 100mg IV and monitor oxygenation with pulse oximetry.
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10-20 minutes -
- Administer lorazepam, 0.1 mg/kg (up to 4 mg) at 2 mg/min IV, or diazepam 0.2 mg/kg (up to 10mg) at 5 mg/min IV; if an IV is not in place may use midazolam 0.2 mg/kg max 10 mg until one is available; and
- Repeat in 5 minutes if seizure persists.
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21-60 minutes -
- If seizure persists, load with fosphenytoin (preferred for children) IV at 15-20 mg/kg (in phenytoin equivalents) at 150 mg PE/min or 3mg PE/kg/min.
- If phenytoin is used, the dose is 15-20 mg/kg at 1 mg/kg/min IV while monitoring ECG and blood pressure. Infusion should be slowed if dysrhythmia or QT interval widening develops.
- If seizure persists for 15 minutes after using phenytoin, additional doses of fosphenytoin/phenytoin may be given at 5mg/kg (up to 30 mg/kg total).
- If seizures persist, give phenobarbital 20mg/kg IV at 100 mg/min. With the use of phenobarbital following benzodiazepines, the risk of respiratory depression is increased, and the likely need for intubation increases and should be anticipated. [Chin: 2004] If phenobarbital fails to stop the seizure, other measures such as general anesthesia, are usually necessary. For a discussion, see [Abend: 2008]. An algorithm for refractory status epilepticus is presented here as an example: Refractory status epilepticus protocol from Primary Children's Hospital Division of Peds Neurol
Resources
Practice Guidelines
Abend NS, Loddenkemper T.
Pediatric status epilepticus management.
Curr Opin Pediatr.
2014;26(6):668-74.
PubMed abstract / Full Text
Helpful Articles
Wolfe TR, Macfarlane TC.
Intranasal midazolam therapy for pediatric status epilepticus.
Am J Emerg Med.
2006;24(3):343-6.
PubMed abstract
Hirsch, LJ and Arif, H.
Status epilepticus.
Continuum.
2007;13(4):121-151.
Neville BG, Chin RF, Scott RC.
Childhood convulsive status epilepticus: epidemiology, management and outcome.
Acta Neurol Scand Suppl.
2007;186:21-4.
PubMed abstract
Walker DM, Teach SJ.
Update on the acute management of status epilepticus in children.
Curr Opin Pediatr.
2006;18(3):239-44.
PubMed abstract
Appleton R, Macleod S, Martland T.
Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children.
Cochrane Database Syst Rev.
2008(3):CD001905.
PubMed abstract
Raspall-Chaure M, Chin RF, Neville BG, Bedford H, Scott RC.
The epidemiology of convulsive status epilepticus in children: a critical review.
Epilepsia.
2007;48(9):1652-63.
PubMed abstract
Lewena S, Pennington V, Acworth J, Thornton S, Ngo P, McIntyre S, Krieser D, Neutze J, Speldewinde D.
Emergency management of pediatric convulsive status epilepticus: a multicenter study of 542 patients.
Pediatr Emerg Care.
2009;25(2):83-7.
PubMed abstract
Page Bibliography
Abend NS, Dlugos DJ.
Treatment of refractory status epilepticus: literature review and a proposed protocol.
Pediatr Neurol.
2008;38(6):377-90.
PubMed abstract
Chin RF, Verhulst L, Neville BG, Peters MJ, Scott RC.
Inappropriate emergency management of status epilepticus in children contributes to need for intensive care.
J Neurol Neurosurg Psychiatry.
2004;75(11):1584-8.
PubMed abstract / Full Text