What is the initial treatment protocol for pediatric seizures?

Pediatric Seizure Protocol

Initial Stabilization (0-5 Minutes)

For any pediatric seizure, immediately assess circulation, airway, and breathing (CAB), provide airway protection, administer high-flow oxygen to prevent hypoxia, and check blood glucose immediately to rule out hypoglycemia. 1, 2

Key Initial Actions:

• Secure airway and provide 100% oxygen 1, 2
• Establish IV or intraosseous access 3
• Check bedside glucose immediately - hypoglycemia is a rapidly reversible cause 1, 2
• Monitor vital signs and oxygen saturation continuously 3

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First-Line Treatment: Benzodiazepines (0-5 Minutes)

Administer lorazepam 0.1 mg/kg IV (maximum 2 mg) slowly as first-line therapy for active seizures; may repeat once after at least 1 minute (maximum of 2 doses). 2

Benzodiazepine Options:

• Lorazepam 0.1 mg/kg IV (preferred, maximum 2 mg per dose) 3, 2, 4

  • Can repeat once if seizure continues after 1 minute
  • Superior efficacy profile in network meta-analysis 4
  • Equivalent efficacy to diazepam-phenytoin combination with simpler single-drug regimen 5

• Alternative: Diazepam 0.2 mg/kg IV (maximum dose varies by route) 3, 6

  • Less preferred than lorazepam based on comparative data 4

• If no IV access: Midazolam (non-IV routes) 4

  • Nonintravenous midazolam shows superior efficacy to nonintravenous diazepam 4

Critical Caveat:

Monitor closely for respiratory depression, especially when benzodiazepines are combined with other sedative agents - this is the most common serious adverse effect. 2 Have airway management equipment immediately available. 3

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Second-Line Treatment: If Seizures Persist (5-20 Minutes)

If seizures continue after benzodiazepine administration, immediately administer levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg). 2

Alternative Second-Line Agents:

• Fosphenytoin 18-20 mg PE/kg IV 3, 7, 6

  • Maximum rate: 2 mg PE/kg/min (or 150 mg PE/min, whichever is slower) in pediatric patients 7
  • Slower administration rate critical to avoid cardiovascular complications 7
  • Monitor for hypotension and cardiac arrhythmias during infusion 7

• Phenobarbital 15-20 mg/kg IV over 10 minutes 3, 6

  • Strict adherence to proper administration rate essential 6

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Third-Line Treatment: Refractory Status Epilepticus (20-40 Minutes)

For seizures continuing beyond 20 minutes despite first and second-line therapy, add phenobarbital 10-20 mg/kg IV (maximum 1,000 mg) and initiate continuous EEG monitoring. 2

Additional Interventions:

• Transfer to Pediatric Intensive Care Unit (PICU) for ongoing management 2
• Initiate continuous EEG monitoring for refractory seizures 2
• Consider corticosteroids if indicated by underlying etiology 2
• Prepare for possible intubation and mechanical ventilation if seizures persist 3

Fourth-Line Options (Refractory Cases):

• Pentobarbital infusion - 92% treatment success rate but 77% risk of hypotension requiring pressors 3
• Midazolam infusion - 80% success rate, 30% hypotension risk 3
• Propofol infusion - 73% success rate, 42% hypotension risk 3
• Valproic acid IV - effective in 58-83% of refractory cases 3, 8

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Maintenance Therapy After Seizure Control

Once seizures are controlled, administer lorazepam 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses. 2

Maintenance Options:

• 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 1,500 mg) 2
• Phenobarbital 1-3 mg/kg IV every 12 hours if used in acute management 2

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Special Considerations

Neonatal Seizures:

• Follow same CAB assessment and glucose check protocol 1
• Withdrawal-associated seizures are primarily myoclonic, respond to opiates, and carry no increased long-term risk 1

Febrile Seizures (Simple):

• No prophylactic anticonvulsant therapy recommended for simple febrile seizures (brief, generalized, single episode in 24 hours) 3
• Antipyretics are ineffective in preventing febrile seizure recurrence 3
• Reassure caregivers - simple febrile seizures do not cause long-term neurological damage, IQ decline, or significantly increase epilepsy risk 3

Prolonged Seizures During Treatment:

• Seizures lasting >180 seconds on EEG should be treated with additional methohexital, diazepam, or lorazepam 3
• Monitor for tardive seizures (late-onset seizures occurring 24-48 hours after recovery) 3

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Common Pitfalls to Avoid

1. Inadequate respiratory monitoring - benzodiazepines cause respiratory depression, especially with combination therapy 2
2. Excessive fosphenytoin infusion rate - must not exceed 2 mg PE/kg/min in children to avoid cardiovascular collapse 7
3. Failure to check glucose early - hypoglycemia is rapidly reversible and commonly missed 1, 2
4. Delaying second-line therapy - if seizures persist beyond 5 minutes after benzodiazepines, immediately proceed to levetiracetam or fosphenytoin 2
5. Using prophylactic anticonvulsants for simple febrile seizures - toxicity outweighs minimal benefits 3