Acute seizure and status epilepticus management (< 18 years)



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Acute seizure and status epilepticus management (< 18 years)

< 2 months of age?

Hypotension or myocardial infarction?

Seizure terminated?

Seizure precautions, off pathway, start appropriate pathway

5-10 min

10-20 min

20-40 min

Management Goals

  • Treatment of seizures should begin rapidly, within 5 minutes of seizure onset, andcontinue sequentially until all clinical and electrographic seizures are terminated,ideally within 60 minutes of onset.
  • Etiology of seizures should be diagnosed and treated as soon as possible
  • Both treatment and diagnostic evaluation should be started simultaneously

Give Lorazepam dose and prepare 2nd line medication

Lorazepam injection

Seizure precautions, consider video EEG for any concern of subclinical seizures, admit, off pathway

Defining status epileptics

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

Signs of CNS infection?

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

Seizure terminated?

IV access secured?

Seizure precautions, off pathway, start appropriate pathway

Seizure terminated?

Seizure terminated?

Seizure precautions, off pathway, start appropriate pathway

  • Neurology consult
  • Assess laboratory findings and supplement electrolytes is necessary
  • Start Medications
  • Dose #1: Phenobarbitol 20 mg/kg IV
  • Dose #2 (if continued seizure 5 min after first dose): Phenobarbitol 10 mg/kg IV (max total 30 mg/kg) at 1mg/kg/min

Phenobarbital injection

Consider neurology consultation

Cardiac arrhythmias and syncope are often confused with epileptic activity. Consider ECG in any patient with non-classical signs for seizure.

  • Give antibiotics immediately
  • Blood culture and lumbar puncture delayed after seizures under control

Ceftriaxone injection
Vancomycin injection
  • Begin cardiopulmonary resuscitation
  • Prepare equipment for bag-mask ventilation
  • Obtain IV access
  • Obtain drug levels of anti-epileptic medications if appropriate
  • Prepare Lorazepam 0.1 mg/kg IV (max 4 mg)
  • Prepare Midazolam 0.2 mg/kg Intranasal (max 10 mg)

Complete Blood Count, Serum
Complete Metabolic Panel, Serum
Urine Pregnancy, Urine
Glucose by Meter, POC
Magnesium, Serum
Phosphorus, Serum
Alcohol Volatile Screen, Serum
Urine Toxicology, Urine

0-5 min

  • Neurology consult
  • Assess laboratory findings and supplement electrolytes is necessary
  • Start Medications
  • Dose #1: Fosphenytoin 20 mg/kg IV over 10 min
  • Dose #2 (if continued seizure 5 min after first dose): Phenobarbitol 20 mg/kg IV (max total 30 mg/kg) at 1mg/kg/min

Phenobarbital injection
Fosphenytoin injection
  • Continuous EEG
  • Strongly consider rapid sequence intubation
  • Start continuous midazolam infusion
  • ICU admission
  • Midazolam infusion can be increased by 0.05-0.1 mg/kg/hr every 15-30 min to goal (clinical seizure suppression, or burst suppression as noted on continuous EEG)- max dose 1mg/kg/hr (higher doses have been used)

  • Neurology consult
  • Assess laboratory findings and supplement electrolytes is necessary
  • Start Medications
  • Dose #1: Levetiracetam 40 mg/kg IV (max 3,000 mg) over 10 min
  • Dose #2 (if continued seizure 5 min after first dose): Levetiracetam 20 mg/kg IV (max 1,500 mg) over 10 min

Levetiracetam injection

Avoid using flumazenil in patients with suspicion of seizure as it may potential refractory seizure activity.

Give Midazolam, obtain IV access and prepare Lorazepam 0.1 mg/kg IV (max 4 mg). Midazolam may be given through intramuscular, intranasal, oral, buccal, or rectal routes.

Midazolam 10mg/mL intranasal solution

Give Lorazepam dose and prepare 2nd dose

Lorazepam injection



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