What are the steps for managing status epilepticus, including initial medication, dosage, and potential labs?

Status Epilepticus Management Protocol for 14-Year-Old Patient

Lorazepam is the first-line treatment for status epilepticus in a 14-year-old patient, administered at 0.1 mg/kg IV (maximum 2 mg) which may be repeated once after 1 minute if seizures persist. 1

Initial Assessment and Stabilization (0-5 minutes)

• 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 potential cause 1
• Simultaneously search for and treat underlying causes including medication non-compliance (as in this case with missed levetiracetam), hypoglycemia, hyponatremia, hypoxia, drug toxicity, CNS infections, and withdrawal syndromes 2
• Establish IV access immediately 2

First-Line Treatment (0-5 minutes)

• Administer lorazepam 0.1 mg/kg IV (maximum 2 mg) slowly; may repeat dose after at least 1 minute (maximum of 2 doses) 1
• For this 14-year-old patient who already received rescue medication at home without effect, proceed directly to IV lorazepam 1
• Equipment necessary to maintain a patent airway should be immediately available prior to intravenous administration of lorazepam 3
• Monitor for respiratory depression, which is the most important risk associated with lorazepam in status epilepticus 3

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 options include valproate 30 mg/kg IV at 5-6 mg/kg/min (with lower risk of hypotension compared to phenytoin) 2
• Or phenytoin/fosphenytoin 20 mg/kg IV at maximum 50 mg/min with continuous ECG and blood pressure monitoring 2
• For this patient who normally takes levetiracetam, using IV levetiracetam as second-line therapy is particularly appropriate 2

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
• Initiate continuous electroencephalography (EEG) monitoring for refractory seizures 1
• Consider corticosteroids if indicated by underlying etiology 1

Refractory Status Epilepticus Management (>40 minutes)

• If seizures persist despite the above measures, consider propofol 2 mg/kg bolus followed by 3-7 mg/kg/hour infusion 2
• Transfer to Pediatric Intensive Care Unit (PICU) for ongoing management 1
• Consider ketamine 1 mg/kg IV as an alternative agent for refractory status epilepticus before intubation 4

Maintenance Therapy After Seizure Control

• For this patient already on levetiracetam, administer 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
• Administer lorazepam 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 1
• If phenobarbital was used in acute management, continue at 1-3 mg/kg IV every 12 hours 1

Laboratory Tests to Order

• Complete blood count (CBC) 4
• Comprehensive metabolic panel (CMP) including electrolytes, glucose, liver and kidney function 4
• Antiepileptic drug levels (particularly levetiracetam in this case) 2
• Toxicology screen if drug toxicity is suspected 2
• Blood cultures if infection is suspected 2

Role Assignments for Simulation

• Team Leader: Directs overall management, makes treatment decisions, and coordinates team efforts
• Record Keeper/Timekeeper: Documents all interventions, medications, vital signs, and tracks time since seizure onset and between medication administrations 2
• Medication/IV Administrator: Prepares and administers medications, maintains IV access 2
• Assessment/Monitor: Continuously monitors vital signs, oxygen saturation, and seizure activity 2
• Respiratory Support: Manages airway and provides respiratory support as needed 2

Common Pitfalls and Caveats

• Inadequate respiratory monitoring when using benzodiazepines, which can cause respiratory depression, especially when combined with other sedative agents 1
• Delays in progressing to second-line agents - move to the next treatment step if seizures continue after 5-10 minutes 2
• Insufficient dosing of benzodiazepines - many patients receive inadequate doses 5
• Failure to identify and address the underlying cause - in this case, missed levetiracetam doses due to vomiting/diarrhea 2
• Not monitoring for cardiovascular complications with phenytoin administration, including cardiac arrhythmias and hypotension 2

Special Considerations for This Patient

• This patient's status epilepticus likely resulted from missed levetiracetam doses due to vomiting and diarrhea 2
• Home rescue medication was ineffective, indicating the need for more aggressive hospital-based treatment 1
• After stabilization, address the need for an alternative administration route for maintenance levetiracetam during periods of gastrointestinal illness 2
• Educate family on importance of maintaining therapeutic levels of antiepileptic medications and when to seek medical attention 2