Initial management of status epilepticus in children

Timeline*	Assessment	Supportive care	Seizure therapy
0 to 5 minutes	Obtain initial vital signs, including temperature	Open airway Suction secretions Administer 100% O₂	Benzodiazepine: Lorazepam 0.1 mg/kg IV or IO, maximum 4 mg OR Diazepam 0.2 mg/kg IV or IO, maximum 10 mg IV or IO access not achieved within 3 minutes: Buccal midazolam 0.3 to 0.5 mg/kg, maximum 10 mg OR IM midazolam 0.1 to 0.2 mg/kg, maximum 10 mg OR Rectal diazepam (Diastat gel or injection solution given rectally) 0.5 mg/kg, maximum 20 mg
	Identify airway obstruction and hypoxemia	Place continuous cardiorespiratory monitors and pulse oximetry
	Identify impaired oxygenation or ventilation	Perform bag-valve-mask ventilation, as needed Prepare for RSI*
	Obtain rapid bedside blood glucose and other studies, as indicated^¶	Establish IV or IO access
	Evaluate for signs of sepsis/meningitis	Treat hypoglycemia (IV dextrose 0.25 to 0.5 g/kg)
	Evaluate for signs of head trauma	Treat fever (acetaminophen 15 mg/kg rectally)
5 to 10 minutes	Reevaluate vital signs, airway, breathing, and circulation	Maintain monitoring, ventilatory support, and vascular access	Benzodiazepine: second dose
5 to 10 minutes	Evaluate for signs of trauma, sepsis, meningitis, or encephalitis	Give antibiotics if signs of sepsis or meningitis^Δ	Benzodiazepine: second dose
10 to 15 minutes	Reevaluate vital signs, airway, breathing, and circulation	Maintain monitoring, ventilatory support, and vascular access	Levetiracetam 60 mg/kg IV or IO, maximum single dose 4500 mg OR Fosphenytoin 20 mg PE per kg IV or IO, maximum single dose 1500 mg^◊ OR Valproate 20 to 40 mg/kg IV or IO OR Phenobarbital 20 mg/kg IV or IO, maximum 1 g (expect a respiratory depression with apnea)^¥
		Place second IV
		RSI potentially indicated*
15 to 30 minutes	Reevaluate vital signs, airway, breathing, and circulation	Maintain monitoring, ventilatory support, and vascular access	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, maximum 1 g (10 mg/kg if phenobarbital already given)^¥ OR Levetiracetam (if not already given) 60 mg/kg IV or IO AND Pyridoxine 100 mg IV or IO in infants <1 year of age Pyridoxine 70 mg/kg IV or IO, maximum 5 g, if INH poisoning suspected Obtain pediatric neurology consultation^‡
15 to 30 minutes	Obtain continuous EEG monitoring, if available

RSI: rapid sequence endotracheal intubation; IV: intravenous; IO: intraosseous; IM: intramuscular; O₂: oxygen; PE: phenytoin equivalents; EEG: electroencephalogram; INH: isoniazid.
* Rapid sequence intubation should be performed if airway, ventilation, or oxygenation cannot be maintained and if the seizure becomes prolonged.
¶ For ancillary studies to obtain in children with status epilepticus, refer to UpToDate topics on status epilepticus in children.
Δ Empiric antibiotic regimens vary depending on patient susceptibility and likely pathogen.
◊ Do not exceed 2 mg PE/kg per minute (maximum rate: 150 mg per minute). If fosphenytoin not available, may use phenytoin 20 mg/kg IV, do not exceed 1 mg/kg per minute (maximum rate: 50 mg per minute). Both fosphenytoin and phenytoin infusion require cardiac monitoring. Phenytoin and fosphenytoin may be less effective for the treatment of seizures due to toxins or drugs and may intensify seizures caused by cocaine, other local anesthetics, theophylline, or lindane. In such cases, levetiracetam, valproate, or phenobarbital should be used.
¥ When administering phenobarbital, the maximum infusion rate is 2 mg/kg per minute with a ceiling of 50 mg/min. Anticipate respiratory depression.
‡ In patients with ongoing seizure activity despite two initial doses of benzodiazepine and a second-therapy antiseizure medication, preparation for a continuous infusion of midazolam, propofol, or pentobarbital should occur simultaneously with administration of a third-therapy antiseizure medication.

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Initial management of status epilepticus in children