Status Epilepticus Management in Children
First-Line Treatment: Benzodiazepines (0-5 Minutes)
Administer IV lorazepam 0.1 mg/kg (maximum 4 mg) at 2 mg/min immediately for any actively seizing child—this is the gold standard first-line treatment with 65% efficacy in terminating status epilepticus. 1
Route Selection Based on IV Access
- If IV access is readily available: Give lorazepam 0.1 mg/kg IV (maximum 4 mg per dose), which can be repeated once after at least 1 minute if seizures persist 1
- If IV access is difficult or delayed: Administer midazolam 0.2 mg/kg IM (maximum 6 mg), which is superior to IV lorazepam in prehospital settings with 73.4% seizure cessation versus 63.4% for IV lorazepam 1, 2
- Alternative routes: Buccal or intranasal midazolam 0.2 mg/kg (maximum 6 mg) may be repeated every 10-15 minutes 2, 3
Critical Concurrent Actions
- Assess airway, breathing, and circulation (CAB) and provide high-flow oxygen 1
- Check blood glucose immediately and correct hypoglycemia with appropriate dextrose dose based on age and weight 1
- Establish IV or intraosseous access for medication administration 1
- Monitor oxygen saturation continuously and prepare for respiratory support—respiratory depression is the most important risk with benzodiazepines 2, 4
- Have bag-valve-mask ventilation and intubation equipment immediately available 5
Important Caveats
- Lorazepam demonstrates superior efficacy to diazepam (59.1% vs 42.6%) 1
- The risk of apnea increases substantially when benzodiazepines are combined with other sedatives 5
- Never use flumazenil in patients receiving benzodiazepines for seizure control, as it will reverse anticonvulsant effects and may precipitate seizures 2
Second-Line Treatment: Levetiracetam (5-20 Minutes)
If seizures persist after benzodiazepines, immediately administer levetiracetam 40 mg/kg IV (maximum 2,500 mg) as a bolus over 5 minutes—this is the preferred second-line agent due to its 68-73% efficacy and minimal cardiovascular effects. 1
Why Levetiracetam is Preferred
- Superior safety profile: No hypotension risk and no requirement for cardiac monitoring 1
- Ease of administration: Can be given rapidly over 5 minutes without cardiac monitoring 5
- Equivalent efficacy: Recent robust RCT data show no difference in efficacy between levetiracetam, phenytoin, and valproate for established status epilepticus 3
- Minimal adverse effects: Significantly fewer side effects compared to phenytoin or phenobarbital 3
Alternative Second-Line Agents
While levetiracetam is preferred, alternatives include:
Valproate 30 mg/kg IV over 5-20 minutes: 88% efficacy with 0% hypotension risk 2, 5
Fosphenytoin 15-20 mg PE/kg IV at maximum rate of 1-3 mg PE/kg/min (not exceeding 150 PE/min): 84% efficacy but 12% hypotension risk 1, 6
Phenobarbital 20 mg/kg IV over 10 minutes (maximum 1000 mg): 58.2% efficacy but higher risk of respiratory depression and hypotension 2, 5
Dosing Errors to Avoid with Fosphenytoin
- Fatal overdoses have occurred when the concentration (50 mg PE/mL) was misinterpreted to mean total vial content 6
- Each vial contains 100 mg PE (2 mL) or 500 mg PE (10 mL)—verify actual weight and calculate dose as mg PE/kg 1
- Neonates and young infants have altered phenytoin pharmacokinetics increasing toxicity risk—phenobarbital is preferred in this age group 1
Refractory Status Epilepticus (20-40 Minutes)
If seizures persist after benzodiazepines and one second-line agent, immediately transfer to pediatric intensive care unit (PICU) and initiate continuous EEG monitoring. 1
Third-Line Anesthetic Agents
Midazolam infusion is the first-choice third-line agent with 80% overall success rate and 30% hypotension risk (significantly lower than pentobarbital at 77%) 1, 5
Midazolam Dosing Protocol
- Loading dose: 0.15-0.20 mg/kg IV 1, 5
- 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) 1, 2, 5
- EEG monitoring: Essential to guide titration and achieve seizure suppression 5
- Prepare for mechanical ventilation: Respiratory support is required regardless of administration route 5
Alternative Anesthetic Agents
Propofol: 2 mg/kg bolus followed by 3-7 mg/kg/hour infusion—73% efficacy with 42% hypotension risk, requires mechanical ventilation but shorter ventilation time (4 days vs 14 days with barbiturates) 5
Pentobarbital: 13 mg/kg bolus followed by 2-3 mg/kg/hour infusion—highest efficacy at 92% but 77% hypotension risk requiring vasopressors and prolonged mechanical ventilation (mean 14 days) 2, 5
Concurrent Management During Refractory Status
- Load with long-acting anticonvulsant (phenytoin/fosphenytoin, valproate, levetiracetam, or phenobarbital) during midazolam infusion to ensure adequate levels before tapering 5
- Establish IV access and start fluid resuscitation to maintain euvolemia and prevent hypotension 5
- Have vasopressors immediately available (norepinephrine or phenylephrine) as hypotension is nearly universal with anesthetic agents 5
Maintenance Dosing After Seizure Control
Levetiracetam Maintenance
- Convulsive status epilepticus: 30 mg/kg IV every 12 hours (maximum 1,500 mg per dose) 1, 5
- Non-convulsive status epilepticus: 15 mg/kg IV every 12 hours (maximum 1,500 mg per dose) 1, 5
Phenobarbital Maintenance
- 1-3 mg/kg IV every 12 hours 5
Essential Concurrent Management Throughout Treatment
Simultaneously search for and treat underlying causes while administering anticonvulsants—status epilepticus may result from correctable acute causes. 1, 4
Reversible Causes to Investigate
- Hypoglycemia (check fingerstick glucose immediately) 1, 5
- Hyponatremia and other electrolyte abnormalities 1, 5
- Hypoxia 1, 5
- Drug toxicity or withdrawal syndromes 1, 5
- CNS infection (meningitis, encephalitis) 1, 7
- Ischemic stroke or intracerebral hemorrhage 1, 5
- Fever (febrile status epilepticus is common in children) 8, 7
- Subtherapeutic antiepileptic drug concentrations 8
Critical Pitfalls to Avoid
- Never use neuromuscular blockers alone (e.g., rocuronium)—they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 5
- Never skip to third-line agents until benzodiazepines and a second-line agent have been tried 5
- Never delay anticonvulsant administration for neuroimaging—CT scanning can be performed after seizure control is achieved 5
- Never infuse fosphenytoin too rapidly—increases risk of hypotension and cardiac arrhythmias 1, 6
- Never use glucose-containing solutions for phenytoin/fosphenytoin dilution—causes precipitation 2, 6
- Never fail to prepare for respiratory support when combining benzodiazepines with other agents—risk of apnea increases substantially 1, 5
Age-Specific Considerations
- Neonates and young infants: Phenobarbital is preferred over phenytoin due to altered pharmacokinetics and increased toxicity risk with phenytoin 1
- Children under 3 years: Use valproate with extreme caution due to rare hepatotoxicity risk, especially if mitochondrial disorder suspected 3
- Children under 6 years: May require higher mg/kg doses of midazolam than older children and adults 5
- Patients over 50 years: May have more profound and prolonged sedation with benzodiazepines 4
Treatment Timeline Summary
- 0-5 minutes: Benzodiazepines (lorazepam IV or midazolam IM) + check glucose + establish IV access 1, 2
- 5-20 minutes: Levetiracetam 40 mg/kg IV (or alternative second-line agent) 1
- 20-40 minutes: Transfer to PICU, initiate continuous EEG monitoring, start midazolam infusion 1, 5
- >40 minutes: Consider propofol or pentobarbital if midazolam fails, ensure mechanical ventilation established 5