What are the treatment guidelines for status epilepticus in pediatric patients?

Pediatric Status Epilepticus Treatment Guidelines

Initial Stabilization and First-Line Treatment

Administer IV lorazepam 0.1 mg/kg (maximum 4 mg) immediately as first-line treatment for pediatric convulsive status epilepticus, which can be repeated once after at least 1 minute if seizures persist. 1

Critical Immediate Actions

• Assess airway, breathing, and circulation (CAB) and provide high-flow oxygen 2, 1
• Check blood glucose immediately and correct hypoglycemia 1, 3
• Establish IV or intraosseous access 1
• Monitor oxygen saturation continuously and prepare for respiratory support 1

First-Line Benzodiazepine Options

For patients WITH IV access:

• Lorazepam 0.1 mg/kg IV (maximum 4 mg) at 2 mg/min, repeat once after 1 minute if needed 1, 4
• Lorazepam demonstrates 65% efficacy in terminating status epilepticus and is superior to diazepam (59.1% vs 42.6%) 1

For patients WITHOUT IV access:

• Midazolam 0.2 mg/kg IM (maximum 6 mg) is superior to IV lorazepam in prehospital settings, with 73.4% seizure cessation vs 63.4% for IV lorazepam 1
• Intranasal midazolam achieves therapeutic levels within 5-10 minutes and may provide faster administration time 1, 5

Dosing Differences by Seizure Type

• Convulsive status epilepticus: Lorazepam 0.1 mg/kg IV (maximum 2 mg), repeat after 1 minute up to 2 doses 2, 1
• Non-convulsive status epilepticus: Lorazepam 0.05 mg/kg IV (maximum 1 mg), repeat every 5 minutes up to 4 doses 2

Second-Line Treatment (If Seizures Persist After Benzodiazepines)

Administer levetiracetam 40 mg/kg IV (maximum 2,500 mg) as a bolus over 5 minutes immediately after benzodiazepine failure. 2, 1

Second-Line Agent Options (Choose One)

Levetiracetam (Preferred):

• Dose: 40 mg/kg IV bolus (maximum 2,500 mg) over 5 minutes 2
• Efficacy: 68-73% seizure control 1, 3
• Advantages: Minimal cardiovascular effects, no hypotension risk, no cardiac monitoring required 1, 3

Valproate (Alternative):

• Dose: 20-30 mg/kg IV over 5-20 minutes 1, 3
• Efficacy: 88% seizure control with 0% hypotension risk 1, 3
• Avoid in girls of childbearing potential due to teratogenicity risk 1

Fosphenytoin (Traditional Option):

• Dose: 20 mg PE/kg IV at maximum rate of 1-3 mg PE/kg/min or 50 mg PE/min (whichever is slower) 1, 6
• Efficacy: 84% seizure control but 12% hypotension risk 1, 3
• Requires continuous ECG and blood pressure monitoring 3, 6
• Must dilute in normal saline only—incompatible with glucose-containing solutions 1, 6

Phenobarbital:

• Dose: 10-20 mg/kg IV over 10 minutes (maximum 1,000 mg) 2, 1
• Efficacy: 58.2% seizure control 1, 3
• Higher risk of respiratory depression and hypotension 1

Refractory Status Epilepticus (Seizures Persisting After Second-Line Agent)

Transfer patient to pediatric intensive care unit (PICU) immediately and initiate continuous EEG monitoring. 2, 3

Third-Line Anesthetic Agents

Midazolam Infusion (First Choice):

• Loading dose: 0.15-0.20 mg/kg IV 1, 3
• Continuous infusion: Start at 1 mg/kg/min, increase by 1 mg/kg/min every 15 minutes until seizures stop (maximum 5 mg/kg/min) 2, 1, 3
• Efficacy: 80% seizure control with 30% hypotension risk 3

Propofol (Alternative):

• Loading dose: 2 mg/kg bolus 3
• Continuous infusion: 3-7 mg/kg/hour 3
• Efficacy: 73% seizure control with 42% hypotension risk 3
• Requires mechanical ventilation but shorter ventilation time (4 days vs 14 days with pentobarbital) 3

Pentobarbital (Most Effective but Highest Risk):

• Loading dose: 13 mg/kg 3
• Continuous infusion: 2-3 mg/kg/hour 3
• Efficacy: 92% seizure control but 77% hypotension requiring vasopressors 1, 3
• Requires prolonged mechanical ventilation (mean 14 days) 3

Maintenance Dosing After Seizure Control

For Convulsive Status Epilepticus:

• Lorazepam: 0.05 mg/kg IV (maximum 1 mg) every 8 hours for 3 doses 2
• Levetiracetam: 30 mg/kg IV every 12 hours (maximum 1,500 mg) 2, 1
• Phenobarbital: 1-3 mg/kg IV every 12 hours 2

For Non-Convulsive Status Epilepticus:

• Lorazepam: 0.05 mg/kg IV (maximum 1 mg) every 8 hours for 3 doses 2
• Levetiracetam: 15 mg/kg IV (maximum 1,500 mg) every 12 hours 2
• Phenobarbital: 1-3 mg/kg IV every 12 hours 2

Critical Monitoring Requirements

Throughout treatment, continuously monitor:

• Electrocardiogram, blood pressure, and respiratory function 6
• Oxygen saturation with supplemental oxygen available 1
• Observe patient for 10-20 minutes after infusion completion (peak phenytoin concentration period) 6

Common Pitfalls to Avoid

Medication Errors:

• Fosphenytoin concentration misinterpretation: Each vial contains 100 mg PE (2 mL) or 500 mg PE (10 mL), NOT 50 mg PE total—verify actual weight and calculate dose as mg PE/kg 6
• Using glucose-containing solutions with phenytoin causes precipitation 1, 6

Administration Errors:

• Administering benzodiazepines too rapidly increases respiratory depression risk 1
• Exceeding maximum infusion rates for fosphenytoin (2 mg PE/kg/min in pediatrics) causes hypotension and arrhythmias 1, 6
• Using neuromuscular blockers alone only masks motor manifestations while allowing continued brain injury 3

Treatment Delays:

• Skipping directly to third-line agents without trying benzodiazepines and a second-line agent 3
• Delaying treatment for neuroimaging—stabilize seizures first 1
• Failing to prepare respiratory support before administering any benzodiazepine 1

Concurrent Essential Management

Simultaneously search for and treat underlying causes:

• Hypoglycemia, hyponatremia, hypoxia 3
• Drug toxicity or withdrawal syndromes 3
• CNS infection, ischemic stroke, intracerebral hemorrhage 3
• Electrolyte abnormalities 7