Step-by-Step Approach to Managing Status Epilepticus in a Child
The management of status epilepticus in children requires immediate intervention following a structured protocol that prioritizes airway protection, seizure termination, and identification of underlying causes. 1
Initial Assessment and Stabilization
- Assess circulation, airway, and breathing (CAB) and provide appropriate airway protection interventions 1
- Administer high-flow oxygen to prevent hypoxia 1
- Check blood glucose level immediately to rule out hypoglycemia as a cause 1
- Secure intravenous (IV) access for medication administration 2
First-Line Treatment (0-5 minutes)
For convulsive status epilepticus:
- Administer lorazepam 0.1 mg/kg IV (maximum 2 mg) slowly; may repeat dose after at least 1 minute (maximum of 2 doses) 1
- If IV access is unavailable, midazolam can be administered via intramuscular, buccal, or intranasal routes 3
- Transfer patient to Pediatric Intensive Care Unit (PICU) for ongoing management 1
For non-convulsive status epilepticus:
- Administer lorazepam 0.05 mg/kg IV (maximum 1 mg); repeat dose every 5 minutes (maximum of 4 doses) to control electrographical seizures 1
Second-Line Treatment (5-20 minutes)
If seizures persist after benzodiazepine administration:
- Administer levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) 1
- Alternative second-line agents include phenytoin/fosphenytoin or valproic acid if levetiracetam is unavailable 2
- Continue to monitor vital signs and oxygen saturation 4
Third-Line Treatment (20-40 minutes)
If seizures continue:
- Add phenobarbital IV at a loading dose of 10-20 mg/kg (maximum 1,000 mg) 1
- Consider corticosteroids if indicated by underlying etiology 1
- Initiate continuous electroencephalography (EEG) monitoring for refractory seizures 1
Management of Refractory Status Epilepticus (>40 minutes)
If seizures persist despite above measures:
- Transfer to PICU if not already there 5
- Consider anesthetic agents such as midazolam infusion (starting at 0.1 mg/kg/hour, titrating up as needed) 6
- Alternative options include propofol or barbiturate infusions for super-refractory cases 5
- Maintain continuous EEG monitoring to guide treatment 5
Maintenance Therapy After Seizure Control
For convulsive status epilepticus:
- Lorazepam 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 1
- Levetiracetam 30 mg/kg IV every 12 hours or increase prophylaxis dose by 10 mg/kg (to 20 mg/kg) IV every 12 hours (maximum dose of 1,500 mg) 1
- Phenobarbital 1-3 mg/kg IV every 12 hours if used in acute management 1
For non-convulsive status epilepticus:
- Lorazepam 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 1
- Levetiracetam 15 mg/kg (maximum 1,500 mg) IV every 12 hours 1
- Phenobarbital 1-3 mg/kg IV every 12 hours if used in acute management 1
Concurrent Diagnostic Workup
- Obtain urgent laboratory studies: complete blood count, electrolytes, calcium, magnesium, glucose, liver and kidney function tests 7
- Consider lumbar puncture if CNS infection is suspected, as this is a common cause of status epilepticus in children 6
- Neuroimaging (CT or MRI) should be performed once the patient is stabilized 2
- EEG monitoring is essential for diagnosis of non-convulsive status epilepticus and to confirm seizure termination 5
Common Pitfalls and Caveats
- Inadequate dosing of benzodiazepines: Ensure appropriate weight-based dosing and don't hesitate to administer the full recommended dose 4
- Delayed progression to second-line agents: If seizures continue after initial benzodiazepine treatment, promptly initiate second-line therapy 2
- Failure to identify and treat underlying causes: CNS infections are a common cause of status epilepticus in children and are associated with higher mortality 6
- Inadequate respiratory monitoring: Benzodiazepines may cause respiratory depression, especially when combined with other sedative agents 1
- Insufficient EEG monitoring: Continuous EEG is crucial for refractory cases to ensure complete seizure control 5