Acute seizure and status epilepticus management (< 18 years)



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Acute seizure and status epilepticus management (< 18 years)

IV access secured?

Notify Neurology

Fosphenytoin 20 mg/kg (IV or IO) over 20 minutes. Watch for signs of respiratory depression

OR

Midazolam 0.2 mg/kg IV bolus, followed by 0.1 mg/kg/hr infusion. Titrate up to 2 mg/kg/hr for adequate seizure control

Fosphenytoin 20 mg/kg (IV or IO) over 20 minutes. Watch for signs of respiratory depression

Midazolam 0.2 mg/kg IV bolus, followed by 0.1 mg/kg/hr infusion. Titrate up to 2 mg/kg/ hr for adequate seizure control

OR

Pentobarbital 5 mg/kg IV bolus, followed by 1 mg/kg/hr infusion

New Onset Status Epilepticus

5-25 minutes

Refractory Status Epilepticus

>60 minutes

Established Status Epilepticus

25-50 minutes

Notify PCCU

Fosphenytoin 20 mg PE/kg (IV or IO) at a max rate of 3 mg PE/kg/min over 20 minutes

Pyridoxine 200 mg IVP just prior to administration of third antiepileptic drug

Midazolam 0.2 mg/kg IV bolus, followed by 0.1 mg/kg/hr infusion. Titrate up to 2 mg/ kg/hr for adequate seizure control

May give Midazolam 0.2 mg/kg IM. May repeat once for persistent seizures for 5 minutes

Phenobarbital 20 mg/kg ( IV or IO) over 20 minutes

Notify neurology

Notify neurology

Phenobarbital 20 mg/kg (IV or IO) over 20 minutes

IV access secured?

Repeat previous medication once if seizures persist for 5 minutes

Notify PCCU

Consider continuous infusion of Midazolam or Pentobarbital. Watch for signs of respiratory depression

OR

May give additional second line medication (Fosphenytoin, Valproic acid, Levetiracetam or Phenobarbital). Choose a drug not already given

Phenobarbital 10 mg/kg (IV or IO) over 10 minutes

Notify PCCU

Midazolam 0.2 mg/kg IV bolus, followed by 0.1 mg/kg/hr infusion. Titrate up to 2 mg/kg/hr for adequate seizure control

Inclusion Criteria
  • Ongoing seizure activity
Exclusion Criteria
  • Non-epileptic movements

Give Lorazepam OR Diazepam 0.1 mg/kg IV (max dose 4 mg)

Fosphenytoin 20 mg PE/kg (IV or IO) at a max rate of 3 mg PE/kg/min over 20 minutes

OR

Valproic Acid 40 mg/kg (IV or IO) (max dose 3000 mg/dose)

OR

Levetiracetam 60 mg/kg (IV or IO) (max 4500 mg/dose)

OR

For patients under 5 yrs old, consider Phenobarbital 20 mg/kg (IV or IO)

Notify PCCU

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact the Clinical Pathway Oversight Committee at CPOC@montefiore.org.

Disclaimer: Clinical pathways are intended as a resource to guide diagnosis, treatment and management in order to improve quality of care and promote better patient outcomes. They are based on available medical evidence at the time of development; the date on the pathway indicates the most recent update. Pathways are not intended to provide medical advice or consultation regarding the care of any individual patient, and should not replace or supersede a practitioner’s professional opinion or clinical judgment. Because medical knowledge is constantly evolving, and accepting the possibility of error, The Children’s Hospital at Montefiore does not warrant or represent that pathways are complete or accurate. Neither the Hospital nor the individuals involved in the development or publication of the pathways is responsible for results or outcomes related to their use.

Consider neurology consultation

New Onset Status Epilepticus

Arrival to ED/Unit

Zero minutes

Refractory Status Epilepticus

50-60 minutes

Age 2 months or greater?

Defining status epileptics

  • Continuous seizures > 5 min
  • If the seizure continues > 30 min it would have long-term neurologic consequences

  1. Stabilize patient (airway, breathing, circulation).
  2. Place patient on a monitor.
  3. Monitor vital signs.
  4. Apply supplemental oxygen.
  5. Collect finger glucose* stick.
  6. Attempt IV / IO access.
  7. Collect electrolytes, toxicology screen and anticonvulsant drug levels, if applicable.
  8. *If glucose < 40 mg/dl, give 5 ml/kg of D10W IV.

May give Midazolam 0.1 mg/kg IM, or Diazepam PR (max 6-10 mg)

Diazepam PR dosing:

  • 3 mos – 5 years: 0.6 mg/kg PR
  • 6-11 years: 0.3 mg/kg PR
  • >12 years:0.2 mg/kg PR