What is the management of a seizure in a child weighing 5 kilograms (kg)?

Management of Seizure in a 5 kg Child

For a 5 kg child experiencing an active seizure, immediately administer lorazepam 0.5 mg IV/IO (0.1 mg/kg) as first-line therapy after securing the airway and checking blood glucose. 1, 2

Immediate Stabilization

• Assess circulation, airway, and breathing (CAB) immediately and provide airway protection with high-flow oxygen to prevent hypoxia 1, 3
• Check bedside blood glucose immediately to identify hypoglycemia as a rapidly reversible cause of seizures 1, 3
• Establish IV or intraosseous (IO) access for medication administration 1, 2
• Monitor vital signs and oxygen saturation continuously throughout the seizure and post-ictal period 1, 3

First-Line Anticonvulsant Therapy

• Administer lorazepam 0.5 mg IV/IO slowly (0.1 mg/kg for this 5 kg child, maximum 2 mg per dose) 1, 2
• May repeat lorazepam once after at least 1 minute if seizures continue (maximum of 2 doses total) 1, 2
• If IV/IO access unavailable, give midazolam 1 mg IM (0.2 mg/kg) which may be repeated every 10-15 minutes 2
• Alternative: rectal diazepam 2.5 mg (0.5 mg/kg) if no vascular access is available 2

Critical pitfall: Benzodiazepines carry increased risk of respiratory depression, especially when given rapidly IV or in combination with other sedatives—be prepared to provide respiratory support 2, 3

Second-Line Therapy (If Seizures Persist After Benzodiazepines)

• Immediately administer levetiracetam 200 mg IV bolus (40 mg/kg for this 5 kg child, maximum 2,500 mg) 1, 3
• Alternative: phenobarbital 75-100 mg IV/IO (15-20 mg/kg) over 10 minutes 2
• Alternative: fosphenytoin 90-100 mg PE IV (18-20 mg PE/kg) at maximum rate of 10 mg PE/min (2 mg PE/kg/min for this child) 1

Critical pitfall: Delaying second-line therapy beyond 5-10 minutes significantly worsens seizure outcomes 3

Third-Line Therapy (Refractory Seizures >20 Minutes)

• Add phenobarbital 50-100 mg IV (10-20 mg/kg, maximum 1,000 mg) if not already given 1
• Transfer immediately to Pediatric Intensive Care Unit (PICU) 4, 1
• Initiate continuous EEG monitoring to guide further management 4, 1

Maintenance Therapy After Seizure Control

• Lorazepam 0.25 mg IV every 8 hours for 3 doses (0.05 mg/kg, maximum 1 mg) 1, 3
• Levetiracetam 75 mg IV every 12 hours (15 mg/kg) or increase to 100 mg IV every 12 hours (20 mg/kg, maximum 1,500 mg) 1, 3

Special Considerations for Febrile Seizures

• Do NOT administer prophylactic anticonvulsants for simple febrile seizures—antipyretics like acetaminophen are ineffective at preventing febrile seizure recurrence 4, 1, 3
• Reassure caregivers that simple febrile seizures are benign and self-limited 1
• Complex febrile seizures require inpatient observation and appropriate investigations including blood tests and lumbar puncture as indicated 3

When to Activate Emergency Medical Services

Activate EMS for: 4

• First-time seizure
• Seizure lasting >5 minutes
• Multiple seizures without return to baseline between episodes
• Child does not return to baseline within 5-10 minutes after seizure stops
• Seizure with traumatic injuries, choking, or difficulty breathing
• Seizure occurring in water

Critical Pitfalls to Avoid

• Inadequate respiratory monitoring when using benzodiazepines, particularly with combination therapy 1, 3
• Failure to check glucose early leads to missed diagnosis of easily reversible hypoglycemia 1, 3
• Excessive fosphenytoin infusion rate can cause cardiovascular collapse 1
• Using prophylactic anticonvulsants for simple febrile seizures causes unnecessary toxicity without benefit 1, 3
• Restraining the child or placing objects in the mouth during active seizure—these actions cause harm 4