Pediatric Status Epilepticus (AES 2016)

Algorithm Steps

1. ▶

   Start

   Pediatric Convulsive Status Epilepticus

   Seizure ≥5 minutes or 2+ seizures without recovery

   1. ●

      Action

      Stabilization (0-5 min)

      Initial stabilization measures

      • Time the seizure
      • ABCs: Position, suction, O2, monitor
      • Establish IV access (if possible)
      • Check glucose - treat if hypoglycemic
      • Place in recovery position if no IV yet
      1. ●

         Action

         First-Line: Benzodiazepine (5-10 min)

         Give benzodiazepine immediately

         • WITH IV ACCESS:
         • • Lorazepam 0.1 mg/kg IV (max 4 mg) - PREFERRED
         • • OR Diazepam 0.15-0.2 mg/kg IV (max 10 mg)
         • WITHOUT IV ACCESS:
         • • Midazolam 0.2 mg/kg IM (max 10 mg) - PREFERRED
         • • OR Diazepam 0.3-0.5 mg/kg PR (max 20 mg)
         • • OR Midazolam 0.2 mg/kg intranasal
         1. ◆

            Decision

            Seizure Stopped?

            Reassess after 5 minutes

            1. ✓

               Outcome

               Seizure Controlled

               Post-ictal care and monitoring

               • Monitor for recurrence
               • Complete workup: Labs, glucose, electrolytes
               • Consider LP if infection suspected
               • Obtain EEG when stable
               • Start maintenance AED as appropriate
               • Admit for observation
            2. ●

               Action

               Second Benzodiazepine Dose (10-15 min)

               Repeat benzodiazepine if seizure continues

               • Repeat same dose of first-line benzodiazepine
               • • Lorazepam 0.1 mg/kg IV (max 4 mg)
               • • OR Midazolam 0.2 mg/kg IM if no IV
               • Establish IV/IO access if not already done
               1. ◆

                  Decision

                  Seizure Stopped?

                  Reassess after second benzodiazepine

                  1. ●

                     Action

                     Second-Line AED (15-30 min)

                     Add antiepileptic drug for benzodiazepine-refractory SE

                     • Choose ONE:
                     • • Fosphenytoin 20 mg PE/kg IV (max 1500 mg PE)
                     • - Infuse at 3 mg PE/kg/min (max 150 mg PE/min)
                     • • OR Levetiracetam 40-60 mg/kg IV (max 4500 mg)
                     • - Infuse over 15 minutes
                     • • OR Valproate 40 mg/kg IV (max 3000 mg)
                     • - Avoid if metabolic disease, hepatic failure
                     1. ◆

                        Decision

                        Seizure Stopped?

                        Reassess after second-line AED

                        1. ⚠

                           Warning

                           Refractory Status Epilepticus (>30 min)

                           ICU-level care required

                           • Prepare for intubation and continuous infusion
                           • Continuous EEG monitoring if available
                           • Options (consult neurology):
                           • • Midazolam infusion: 0.2 mg/kg bolus, then 0.1-0.4 mg/kg/hr
                           • • Pentobarbital: 5-15 mg/kg bolus, then 0.5-5 mg/kg/hr
                           • • Propofol (>3 yrs): 1-2 mg/kg bolus, then 1-5 mg/kg/hr
                           • • Ketamine: 1-2 mg/kg bolus, then 1-5 mg/kg/hr
                           • Titrate to burst-suppression on EEG