Status Epilepticus Management in Pediatric Patients
Immediate Stabilization (0-5 minutes)
Administer IV lorazepam 0.1 mg/kg (maximum 4 mg per dose) at 2 mg/min immediately for any actively seizing pediatric patient; this terminates status epilepticus in approximately 65% of cases. 1, 2
Airway and Breathing
- Open the airway with head tilt-chin lift maneuver unless cervical spine injury is suspected 3
- Provide 100% high-flow oxygen via bag-mask ventilation immediately 4
- Have airway equipment (bag-valve-mask, intubation set) immediately available before administering any benzodiazepine due to respiratory depression risk 1, 2
- Monitor oxygen saturation continuously throughout treatment 3, 1
Vascular Access
- Establish IV or intraosseous (IO) access immediately; IO access is equivalent to IV access and should be used promptly when IV is difficult 3, 4
- Check fingerstick glucose immediately and correct hypoglycemia 1
Alternative Benzodiazepine Routes (if IV/IO unavailable)
- IM midazolam 0.2 mg/kg (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 or rectal diazepam 0.5 mg/kg are acceptable alternatives 1
- Never use IM diazepam due to erratic absorption 1
Benzodiazepine Dosing Details
- Lorazepam may be repeated once after 10-15 minutes if seizures continue 1
- Prepare for respiratory support regardless of administration route 1
- Apnea can occur up to 30 minutes after the last benzodiazepine dose 1
Second-Line Treatment (5-20 minutes after benzodiazepines)
If seizures persist after adequate benzodiazepine dosing, immediately escalate to a second-line antiepileptic agent without delay. 1, 5
Recommended Second-Line Agents (in order of safety profile)
1. Levetiracetam (preferred for most pediatric patients)
- Dose: 40 mg/kg IV (maximum 2,500 mg) over 5-15 minutes 1
- Efficacy: 68-73% seizure cessation 1, 5
- Minimal cardiovascular effects (0.7% hypotension risk) 5
- No cardiac monitoring required 1
- Maintenance: 30 mg/kg IV every 12 hours (maximum 1,500 mg) for convulsive SE 1
2. Valproate (alternative with superior efficacy)
- Dose: 30 mg/kg IV (maximum 3,000 mg) over 5-20 minutes 1, 5
- Efficacy: 88% seizure cessation with 0% hypotension risk 1, 5
- Absolutely contraindicated in females of childbearing potential due to teratogenicity 1, 5
- Superior safety profile compared to phenytoin 5
3. Fosphenytoin (traditional option)
- Dose: 20 mg PE/kg IV at maximum rate of 1-3 mg PE/kg/min or 50 mg/min (whichever is slower) 1, 5
- Efficacy: 84% seizure cessation 5
- 12% hypotension risk—requires continuous ECG and blood pressure monitoring 1, 5
- Must be diluted in normal saline; incompatible with glucose-containing solutions 1
- Reduce infusion rate if heart rate decreases by 10 beats per minute 1
4. Phenobarbital (reserve option)
- Dose: 20 mg/kg IV (maximum 1,000 mg) over 10 minutes 1, 5
- May repeat after 15 minutes (maximum total dose 40 mg/kg) 1
- Efficacy: 58.2% seizure cessation 1, 5
- Higher risk of respiratory depression and hypotension due to vasodilatory and cardiodepressant effects 1, 5
- Maintenance: 1-3 mg/kg IV every 12 hours 1
Refractory Status Epilepticus (>20 minutes)
Refractory SE is defined as ongoing seizures despite adequate benzodiazepines AND failure of one second-line agent. 5
Critical Actions
- Call anesthesiology for rapid sequence intubation 1
- Initiate continuous EEG monitoring to guide therapy 1, 5
- Prepare for mechanical ventilation 5
Third-Line Anesthetic Agents
1. Midazolam Infusion (first choice)
- Loading dose: 0.15-0.20 mg/kg IV 1, 5
- Continuous infusion: 1 mg/kg/min, titrate up by 1 mg/kg/min every 15 minutes (maximum 5 mg/kg/min) 1, 5
- Efficacy: 80% seizure control 5
- Hypotension risk: 30% 5
- Load a long-acting anticonvulsant (phenytoin, valproate, levetiracetam, or phenobarbital) before tapering midazolam 5
2. Propofol (alternative for intubated patients)
- Bolus: 2 mg/kg IV, then infusion 3-7 mg/kg/hour 1, 5
- Efficacy: 73% seizure control 5
- Hypotension risk: 42% 5
- Requires mechanical ventilation but shorter duration than barbiturates (4 days vs 14 days) 5
- Continuous blood pressure monitoring essential 5
3. Pentobarbital (highest efficacy, highest complications)
- Bolus: 13 mg/kg IV, then infusion 2-3 mg/kg/hour 5
- Efficacy: 92% seizure control 5
- Hypotension risk: 77% requiring vasopressors 5
- Mean mechanical ventilation duration: 14 days 5
Concurrent Management Throughout Treatment
Search for Reversible Causes
- Hypoglycemia (check fingerstick immediately) 1, 5
- Hyponatremia 5
- Hypoxia 5
- Drug toxicity or withdrawal 5
- CNS infection 5
- Ischemic stroke or intracerebral hemorrhage 5
Monitoring Requirements
- Continuous oxygen saturation 3, 1
- Continuous blood pressure monitoring (especially with phenytoin, propofol, pentobarbital) 1, 5
- Continuous EEG in refractory cases 5
- Cardiac monitoring with fosphenytoin 1, 5
CPR Quality (if cardiac arrest occurs)
- Compression depth: at least one-third of anteroposterior chest diameter 3
- Rate: 100-120 compressions per minute 3
- Ratio: 15 compressions:2 breaths with two rescuers; 30:2 with single rescuer 3
- Minimize interruptions; change compressor every 2 minutes 3
Critical Pitfalls to Avoid
- Do not delay second-line treatment waiting for benzodiazepines to work beyond 10-15 minutes 1, 5
- Do not underdose benzodiazepines—76-81% of midazolam and lorazepam administrations are underdosed in practice 6
- Do not use neuromuscular blockers alone (e.g., rocuronium)—they only mask motor manifestations while allowing continued brain injury 5
- Do not skip to third-line agents until benzodiazepines and one second-line agent have been tried 5
- Do not use flumazenil in patients receiving benzodiazepines for seizure control—it reverses anticonvulsant effects and may precipitate seizures 1
- Do not use phenytoin with glucose-containing solutions—causes precipitation 1
- Do not administer benzodiazepines too rapidly IV—increases respiratory depression risk 1
- Do not use valproate in females of childbearing potential 1, 5