What is the first-line treatment for pediatric patients experiencing seizures?

First-Line Treatment for Pediatric Seizures

Administer benzodiazepines immediately as first-line treatment for any actively seizing pediatric patient, with IV lorazepam or IV diazepam being the preferred agents when IV access is available. 1, 2, 3

Immediate First-Line Management

Benzodiazepine Selection and Dosing

• IV lorazepam is preferred over diazepam due to its longer duration of action, though both are equally effective at terminating seizures 3
• For IV diazepam in children under 5 years: administer 0.2-0.5 mg/kg slowly over 2 minutes, maximum 5 mg per dose, can repeat every 5-10 minutes 2
• For IV lorazepam: administer 4 mg at 2 mg/min (adult dosing from guidelines applies proportionally to pediatric weight-based dosing) 1
• When IV access is unavailable or delayed, intramuscular midazolam is equally efficacious and should be used without hesitation 1
• Intranasal or buccal midazolam are acceptable alternatives, showing 88-93% efficacy in stopping seizures within 10 minutes 1

Critical Concurrent Actions

• Check fingerstick glucose immediately while administering benzodiazepines and correct hypoglycemia if present 1
• Have airway equipment immediately available before administering any benzodiazepine, as respiratory depression can occur 1
• Monitor vital signs continuously and be prepared to provide respiratory support 1
• Never delay benzodiazepine administration to obtain additional history or imaging, as time-to-treatment directly influences outcome and mortality 2

Second-Line Treatment (If Seizures Persist After Benzodiazepines)

Administer a long-acting anticonvulsant immediately after benzodiazepines if seizures persist beyond 5-10 minutes. 2

Preferred Second-Line Agents

• Valproate 30 mg/kg IV over 5-20 minutes achieves 88% seizure cessation within 20 minutes and is preferred over phenytoin 1, 3
• Levetiracetam 30 mg/kg IV over 5 minutes demonstrates 68-73% efficacy in refractory status epilepticus 1, 3
• Fosphenytoin 20 mg PE/kg IV at maximum rate of 50 mg/min has 84% efficacy but carries 12% risk of hypotension 1
• Phenobarbital should never be used as first-line treatment, as it performs significantly worse than all other options 1

Treatment Algorithm

• If seizures continue 5-10 minutes after first benzodiazepine dose, repeat the benzodiazepine dose 2
• Simultaneously begin infusion of valproate or levetiracetam as the long-acting anticonvulsant 2, 3
• Search for underlying reversible causes: hypoglycemia, hyponatremia, hypoxia, CNS infection, ischemic stroke, or intracerebral hemorrhage 1, 3

Third-Line Treatment for Refractory Status Epilepticus

If seizures persist after benzodiazepines plus a second-line agent, initiate anesthetic therapy with midazolam infusion. 1

• Midazolam: loading dose 0.15-0.20 mg/kg IV, then continuous infusion 1 mg/kg/min, titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min 1
• Propofol: 2 mg/kg bolus followed by 3-7 mg/kg/hour infusion, with 73% seizure control rate 1
• Pentobarbital: highest efficacy at 92% seizure control but carries 77% hypotension risk 1

Critical Pitfalls to Avoid

• Never administer diazepam intramuscularly, as this route causes tissue necrosis and is contraindicated 2
• Never use neuromuscular blockers alone, as they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 1
• Never skip to third-line agents until benzodiazepines and a second-line agent have been tried 1
• Never put anything in the mouth of a seizing patient or give oral medications during an active seizure 1
• Never restrain the person having a seizure 1
• Never delay second-line treatment, as delaying increases morbidity and mortality 1

When to Activate Emergency Medical Services

• Activate EMS immediately for: first-time seizures, seizures lasting >5 minutes, multiple seizures without return to baseline mental status between episodes, seizures occurring in water, seizures with traumatic injuries, difficulty breathing or choking, seizure in infant <6 months of age, seizure in pregnant individuals, or individual does not return to baseline within 5-10 minutes after seizure stops 1, 3

Special Considerations for Febrile Seizures

• Antipyretics (acetaminophen, ibuprofen, paracetamol) are NOT effective for stopping a febrile seizure or preventing subsequent febrile seizures in children 1, 3
• Long-term antiepileptic prophylaxis is NOT recommended for simple febrile seizures, as the risks of medication toxicity outweigh the benign nature of febrile seizures 3
• For acute treatment of a prolonged febrile seizure, rectal diazepam is the treatment of choice 4