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

First-Line Treatment for Pediatric Seizures

Benzodiazepines are the definitive first-line treatment for any actively seizing pediatric patient, with intravenous lorazepam or diazepam being the preferred agents when IV access is available. 1, 2, 3

Immediate Management Algorithm

For Active Seizures (>5 minutes or recurrent without recovery)

First-Line Benzodiazepine Administration:

• Administer IV lorazepam 0.05-0.1 mg/kg (maximum 4 mg) at 2 mg/min - this is the preferred benzodiazepine due to its longer duration of action and demonstrates 65% efficacy in terminating status epilepticus 1, 3

• Alternative: IV diazepam 0.2-0.5 mg/kg (maximum 5 mg for children <5 years, 10 mg for older children) over 2 minutes - equally effective when IV access exists 2, 3

• If IV access unavailable or delayed: Intramuscular midazolam 0.2 mg/kg - equally efficacious to IV lorazepam in prehospital settings 1

• Alternative non-IV routes: Intranasal or buccal midazolam - demonstrates 88-93% efficacy in stopping seizures within 10 minutes 1

Critical Concurrent Actions:

• Check fingerstick glucose immediately and correct hypoglycemia while administering benzodiazepines 1
• Have airway equipment immediately available before administering lorazepam, as respiratory depression can occur 1
• Monitor vital signs continuously and prepare to provide respiratory support 1
• Stabilize airway, breathing, and circulation 3

Second-Line Treatment (if seizures persist after 5-10 minutes)

The benzodiazepine dose can be repeated once, then immediately proceed to a long-acting anticonvulsant: 2

• Valproate 30 mg/kg IV over 5-20 minutes (at 6 mg/kg/hour) - achieves 88% seizure cessation within 20 minutes and is the preferred second-line agent 1, 3, 4

• Levetiracetam 30 mg/kg IV over 5 minutes (at 5 mg/kg/minute) - demonstrates 68-73% efficacy in refractory status epilepticus with the lowest probability of respiratory depression 1, 3, 4

• Fosphenytoin 20 mg PE/kg IV at maximum rate of 50 mg/min - has 84% efficacy but carries a 12% risk of hypotension 1

Phenobarbital is also an option but should be used cautiously due to its side effect profile - it ranks best for seizure cessation and lower ICU admission risk among second-line agents 4

Third-Line Treatment for Refractory Status Epilepticus

• Midazolam infusion: 0.15-0.20 mg/kg IV loading dose, then continuous infusion of 1 mg/kg/min, titrated 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 - 73% seizure control rate 1

• Pentobarbital: highest efficacy at 92% seizure control but carries 77% hypotension risk 1

Critical Pitfalls to Avoid

• Never delay benzodiazepine administration to obtain additional history or imaging - time-to-treatment directly influences outcome and mortality 2

• Never use phenobarbital as first-line treatment - it performs significantly worse than benzodiazepines 1

• Never administer diazepam intramuscularly - this route causes tissue necrosis and is contraindicated 2

• Never skip to third-line agents until benzodiazepines and a second-line agent have been tried 1

• Never use neuromuscular blockers alone - they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 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 - delaying increases morbidity and mortality 1

When to Activate Emergency Medical Services

Call EMS immediately for: 1, 3

• First-time seizure
• Seizure in infant <6 months
• Seizure lasting >5 minutes
• Multiple seizures without return to baseline between episodes
• Seizure occurring in water
• Seizure with traumatic injury, choking, or difficulty breathing
• Seizure in pregnant individuals
• Individual does not return to baseline within 5-10 minutes after seizure stops

Essential Concurrent Management

• While administering anticonvulsants, simultaneously search for and treat reversible causes: hypoglycemia, hyponatremia, hypoxia, CNS infection, ischemic stroke, or intracerebral hemorrhage 1, 3

• Consider continuous EEG monitoring if altered mental status is disproportionate to clinical presentation 3

Special Considerations

Febrile Seizures

• Antipyretics (acetaminophen, ibuprofen) do NOT prevent or stop febrile seizures, though they may improve comfort 1, 3

• Long-term antiepileptic prophylaxis is NOT recommended for simple febrile seizures - the risks of medication toxicity outweigh the benign nature of febrile seizures 3

Prophylaxis in High-Risk Patients

• For pediatric patients with CNS disease or history of seizures receiving CAR T-cell therapy: levetiracetam 10 mg/kg (maximum 500 mg per dose) every 12 hours for 30 days following infusion 5