What is the initial treatment for pediatric status epilepticus?

Initial Treatment of Pediatric Status Epilepticus

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

Immediate Stabilization (0-5 minutes)

Before or simultaneously with medication administration:

• Assess airway, breathing, and circulation (CAB) and provide high-flow oxygen 1
• Check blood glucose immediately with fingerstick and correct hypoglycemia 1
• Establish IV or intraosseous access 1
• Prepare continuous oxygen saturation monitoring and have respiratory support equipment immediately available 1, 2

First-Line Treatment (5-20 minutes)

If IV Access Available:

• Lorazepam 0.1 mg/kg IV (maximum 4 mg) at 2 mg/min 1, 2
• Can be repeated once after at least 1 minute if seizures persist 1
• Demonstrates 65% efficacy in terminating status epilepticus 1
• Superior to diazepam (59.1% vs 42.6%) 1, 3

If IV Access NOT Available:

• Midazolam 0.2 mg/kg IM (maximum 6 mg) 1
• Superior to IV lorazepam in prehospital settings (73.4% vs 63.4% seizure cessation) 1
• Can be repeated every 10-15 minutes 4
• Achieves therapeutic levels within 5-10 minutes 4

Critical Monitoring During Benzodiazepine Administration:

• Have bag-valve-mask ventilation and intubation equipment immediately available 1, 2
• Monitor for respiratory depression, especially when combined with other sedatives 4
• Never use flumazenil as it will reverse anticonvulsant effects and may precipitate seizures 4

Second-Line Treatment (20-40 minutes)

If seizures persist after two doses of benzodiazepines, immediately administer levetiracetam 40 mg/kg IV (maximum 2,500 mg) as a bolus over 5 minutes. 1

Why Levetiracetam is Preferred:

• 68-73% efficacy in seizure control 1, 5
• No hypotension risk and no cardiac monitoring required 1
• Minimal cardiovascular effects 1
• Can be administered rapidly over 5 minutes 1

Alternative Second-Line Agents (if levetiracetam unavailable):

Valproate 30 mg/kg IV over 5-20 minutes:

• 88% efficacy with 0% hypotension risk 4, 6
• Superior safety profile compared to phenytoin 6
• CAUTION: Avoid in children under 3 years due to hepatotoxicity risk, especially with mitochondrial disorders 5

Phenytoin/Fosphenytoin 20 mg PE/kg IV:

• Maximum rate: 1 mg PE/kg/min (or 50 mg PE/min, whichever is slower) 4, 7
• 84% efficacy but 12% hypotension risk 6
• Requires continuous cardiac monitoring 6
• Must be diluted in normal saline only (incompatible with glucose solutions) 4
• Monitor heart rate; reduce infusion if heart rate decreases by 10 beats per minute 4

Phenobarbital 20 mg/kg IV over 10 minutes:

• 58.2% efficacy 6
• Higher risk of respiratory depression and hypotension 4
• Maximum total dose: 40 mg/kg 4

Refractory Status Epilepticus (>40 minutes)

If seizures persist after second-line treatment, immediately transfer to PICU and initiate continuous EEG monitoring. 1

Third-Line Anesthetic Agents:

Midazolam infusion (first choice):

• Loading dose: 0.15-0.20 mg/kg IV 1, 6
• Continuous infusion: Start at 1 mg/kg/min 1
• Increase by 1 mg/kg/min every 15 minutes until seizures stop 1
• Maximum: 5 mg/kg/min 1
• 80% success rate with 30% hypotension risk 6

Propofol (alternative):

• 2 mg/kg bolus, then 3-7 mg/kg/hour infusion 6
• 73% efficacy but requires mechanical ventilation 6
• Less hypotension than barbiturates (42% vs 77%) 6

Pentobarbital (most effective but highest risk):

• 13 mg/kg bolus, then 2-3 mg/kg/hour infusion 6
• 92% efficacy but 77% hypotension requiring vasopressors 4, 6
• Requires prolonged mechanical ventilation (mean 14 days) 6

Concurrent Essential Management

Throughout all treatment phases, simultaneously search for and treat underlying causes: 1

• Hypoglycemia 1
• Hyponatremia 1
• Hypoxia 1
• Drug toxicity or withdrawal syndromes 1
• CNS infection 1
• Ischemic stroke 1
• Intracerebral hemorrhage 1
• Electrolyte abnormalities 1

Common Pitfalls to Avoid

• Never delay benzodiazepine administration - every minute increases morbidity and mortality risk 4
• Never use neuromuscular blockers alone - they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 6
• Never skip directly to third-line agents - benzodiazepines and a second-line agent must be tried first 6
• Never administer phenytoin with glucose-containing solutions - causes precipitation 4
• Never infuse phenytoin/fosphenytoin too rapidly - increases risk of hypotension and cardiac arrhythmias 4, 7
• Never fail to prepare for respiratory support before administering benzodiazepines - respiratory depression can occur rapidly 1, 2