Paediatric convulsive status epilepticus
Child (not a neonate) with a convulsive seizure for 5 min or more, duration unknown, or repeated seizures without recovery between them.
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PediatricsEmergency
Pediatric Status Epilepticus (AES 2016)
Pediatric Status Epilepticus (AES 2016): Paediatric convulsive status epilepticus → Stabilise; treat at 5 min, or now if duration unknown or airway comp...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Stabilise; treat at 5 min, or now if duration unknown or airway compromised
Assessment and treatment run together. Count seizure time from onset, including time before arrival. Correct low glucose, sodium or calcium at once: the seizure may not stop without it.
- Airway, oxygen, SpO2 and ECG monitoring; suction; recovery position
- IV or IO access; check glucose, VBG, sodium, calcium, magnesium
- Glucose below 3.0 mmol/L: glucose 10% 2 mL/kg IV or IO
- Low sodium with seizure: 3% sodium chloride 3 mL/kg IV over 20 min (max 150 mL); repeat until seizure stops, sodium is 125 mmol/L or more, or sodium has risen 5 mmol/L. Do not delay: anticonvulsants may fail
- Low calcium with seizure: calcium gluconate 10% 0.3-0.6 mL/kg (0.07-0.14 mmol/kg; max 20 mL) IV or IO via a large vein over 10-60 min; ECG monitoring
- Known epilepsy: follow the child's seizure management plan
- Look for a cause: meningitis, head injury (consider non-accidental injury), toxin
- Suspected poisoning: Poisons Information Centre 13 11 26 (AU); isoniazid needs pyridoxine
- Pregnant adolescent: consider eclampsia; give magnesium sulfate per obstetric guideline
- Under 6 months: consider pyridoxine-dependent seizures
03Decision Fewer than 2 benzodiazepine doses given before arrival?
Ask about doses from parents, school or paramedics. Maximum 2 doses in total. If 2 already given: no more benzodiazepine; go to the second-line drug.
- If Yes
04Action Fewer than 2 pre-hospital doses: give benzodiazepine (max 2 in total)
Do not give a drug the child is allergic to or that failed before. If 1 dose was given before arrival, this is the last benzodiazepine dose. Watch for respiratory depression.
- Midazolam 0.15 mg/kg IV, IO or IM (max 10 mg)
- No IV: midazolam 0.3 mg/kg buccal or intranasal (max 10 mg)
- OR lorazepam 0.1 mg/kg IV (max 4 mg); ampoules are 2 mg/mL or 4 mg/mL
- OR diazepam 0.15-0.3 mg/kg IV or IO (max 10 mg); do not give IM
- OR diazepam 0.2-0.5 mg/kg rectal (max 20 mg)
- AES fixed IM midazolam dose: 5 mg for 13-40 kg; 10 mg over 40 kg
05Decision Still seizing 5 min after the benzodiazepine?
- If Yes
06Action Still seizing, only 1 dose given in total: second benzodiazepine dose
If 2 doses have now been given in total (including before arrival), give no more: go to the second-line drug. Call senior staff.
- Same drug and same dose as the first dose
- Get IV or IO access now; prepare the second-line drug
- Monitor breathing; be ready to support the airway
07Decision Still seizing 5 min after the second dose?
- If Yes
08Warning Before second-line drug: Dravet, heart block, phenytoin use, valproate risks
Do not give a drug the child is allergic to or that failed before.
- Phenytoin: not in Dravet syndrome, sodium-channel-blocker poisoning (e.g. tricyclic), sinus bradycardia, SA block or 2nd/3rd degree AV block
- Already taking phenytoin: give levetiracetam or phenobarbitone instead of phenytoin
- Valproate: not under 3 years, in liver disease, suspected mitochondrial (POLG) or urea cycle disorder, pregnancy, or with a carbapenem (e.g. meropenem)
09Action After 2 benzodiazepine doses: give ONE second-line drug
Give a full loading dose. Levetiracetam, phenytoin, fosphenytoin and valproate had similar success in trials. Reassess 5 min after the infusion ends.
- Levetiracetam 40-60 mg/kg IV or IO (max 4.5 g) over 5 min; dilute to 50 mg/mL
- OR phenytoin 20 mg/kg IV or IO (max 2 g) at 1 mg/kg/min (max 50 mg/min); undiluted or at least 5 mg/mL; ECG monitoring
- OR fosphenytoin 20 mg PE/kg IV (max 1500 mg PE) at max 2 mg PE/kg/min or 150 mg PE/min, whichever is slower; ECG and BP monitoring; not on the ARTG
- OR valproate 20-40 mg/kg IV (max 3 g) over 3-10 min; not under 3 years
- OR phenobarbitone 20 mg/kg IV or IO (max 1 g); dilute to 20 mg/mL or weaker; over 30 min or longer (max 1 mg/kg/min); ECG monitoring
10Decision Still seizing 5 min after the second-line infusion ends?
- If Yes
11Action Still seizing: give a different second-line drug and prepare RSI
Give a second-line drug not yet given (doses above); prefer levetiracetam or phenytoin. Check the cautions above. Call senior staff with airway skills.
- Already taking phenytoin: phenobarbitone 20 mg/kg IV or IO (max 1 g) if not yet given
- Senior staff: prepare RSI and ventilation
- Call PICU or the paediatric retrieval service
- Reassess 5 min after the infusion ends
12Decision Still seizing 5 min after the second infusion ends?
- If Yes
13Action Refractory status epilepticus: RSI, ventilation and anaesthetic infusion in PICU
Only senior staff confident with paediatric airway management. Doses per PICU or anaesthetic protocol.
- Infusion options: midazolam, ketamine, propofol or thiopentone; pentobarbital where available
- Propofol: risk of propofol infusion syndrome with high-dose or prolonged infusion
- Continuous EEG monitoring when available
- Under 6 months: pyridoxine 100 mg IV
- Keep treating the cause: glucose, electrolytes, infection, toxin, raised ICP
14Outcome PICU care: continuous EEG, treat the cause, plan maintenance therapy
Transfer with the paediatric retrieval service if not in a centre with PICU.
If No15Outcome Seizure stopped: post-seizure care and look for the cause
Recovery position, airway and breathing checks, monitor for further seizures.
- Electrolytes, calcium and VBG if a second-line drug was needed, age under 12 months, or not back to baseline
- Not back to baseline when the post-ictal phase and drug effect should have passed: senior review; consider imaging and EEG for ongoing non-convulsive seizures
- Imaging if trauma, focal seizure, third-line treatment, under 6 months, raised ICP signs, bleeding disorder or anticoagulant
- Suspected meningitis: treat per meningitis guideline
- Discuss with the paediatric team; admit if under 12 months, prolonged seizure or incomplete recovery
- Before discharge: seizure first aid, a management plan, consider buccal midazolam
If No- Path rejoins step 15Shared downstream outcome
If No- Path rejoins step 15Shared downstream outcome
If No- Path rejoins step 15Shared downstream outcome
If No- Path rejoins step 08Shared downstream outcome
Guideline Source
Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults. Report of the Guideline Committee of the American Epilepsy Society (Glauser et al., 2016)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Not for neonates (under 28 days): use a neonatal seizure guideline
- Refractory-stage infusion doses are not given: use the local PICU protocol
- Where AES 2016 and RCH 2025 doses differ, both are within the stated ranges; follow the local formulary
Contraindicated Populations
Neonates (under 28 days)
Applicable Regions
USEUAU
AU: Doses follow the RCH Melbourne CPG Seizures - acute management (June 2025). Midazolam is first-line. Levetiracetam or phenytoin is second-line. Fosphenytoin and pentobarbital are not on the ARTG. Poisons Information Centre 13 11 26.
US: AES 2016 lists fosphenytoin, valproate or levetiracetam as second-line and pentobarbital as a third-phase option.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Pediatric Status Epilepticus (AES 2016)?
The Pediatric Status Epilepticus (AES 2016) is a emergency clinical algorithm for Pediatrics. It provides a structured decision tree to guide clinical decision-making, based on Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults. Report of the Guideline Committee of the American Epilepsy Society (Glauser et al., 2016).
What guideline is the Pediatric Status Epilepticus (AES 2016) based on?
This algorithm is based on Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults. Report of the Guideline Committee of the American Epilepsy Society (Glauser et al., 2016) (DOI: 10.5698/1535-7597-16.1.48).
What are the limitations of the Pediatric Status Epilepticus (AES 2016)?
Known limitations include: Not for neonates (under 28 days): use a neonatal seizure guideline; Refractory-stage infusion doses are not given: use the local PICU protocol; Where AES 2016 and RCH 2025 doses differ, both are within the stated ranges; follow the local formulary. Individual patient factors may require deviation from these recommendations.
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