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Management of Status Epilepticus:

Emergency Department Management Clinical Practice Guideline (CPG)

Protocol approved by: Divisions of Pediatric Emergency Medicine,

Pediatric Neurology and PharmacyDate of approval:

cardinalglennon.com

Less Than 1 Month of Age:

- Repeat IV Phenobarbital 20 mg/kg

Time 20 minutes: Monitor airway, consider intubation if impending airway compromise (see “intubated

child” if intubated)

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Greater Than 1 Month of Age: - Repeat IV Fosphenytoin 10 mg/kg over 5

min (or give 20mg/kg if using for the first

time)

And

- Consider intubation at this time

Time 30 minutes: Strongly consider intubation if starting a versed drip

Intubation of neonate may be delayed if airway is not compromised

Less Than 1 Month of Age: - Continuous EEG

- If neonate has received a total of

40mg/kg of IV Phenobarbital then chose

from below:

- IV Fosphenytoin 20mg/kg once

Or

Levetiracetam (Keppra)9

60mg/kg once

Greater Than 1 Month of Age: - Rapid sequence intubation

- IV Midazolam infusion:

- Bolus 0.15-0.3 mg/kg q5 min till seizure

cessation (max 2mg/kg)

- Maintenance 0.1 mg/kg/hr

- Titrate rate by 0.1mg/kg q15 minutes

- Continuous EEG

Time 60 minutes: Both neonate and older child; should be intubated by this time

Patient should be on EEG

Obtain anti-epileptic drug levels one hour after loads were given

Follow up on labs collected earlier, treat as indicate

Discuss with neurology if maintenance medication is required, to start 12 hours after the

loading dose

Other considerations: Diagnostic testing:

1. Infection:

- Obtain Blood Cultures/HSV PCR

- Urinalysis

- Lumbar puncture

- Antibiotics including Acyclovir

- Use antipyretics

2. Intracranial process:

- U/S head in neonate (best yield with open fontanelle)

- MRI brain without contrast

- CT head if MRI cannot be obtained

3. Medication Non-compliance

- Follow anti-epileptic drug levels

Less Than 1 Month of Age: - Rapid sequence intubation (use short

acting paralytic)

- IV Midazolam infusion:

- Bolus 0.15-0.3 mg/kg q5 min till

seizure cessation (max 2mg/kg)

- Maintenance 0.1 mg/kg/hr

- Titrate rate by 0.1mg/kg q15 minutes

- Continuous EEG

Consider:

- **Pyridoxine8

100mg slow IV push

(monitors must be in place)

**If partial response to pyridoxine, repeat 100mg IV push till Max of 500mg

Special Considerations: Treatment of Electrolyte Imbalance:

Hypoglycemia:

Less Than 1 Month of Age:

Treat for Glucose < 40 mg/dl

- Give 4 ml/kg of IV D10, plus start

continuous Dextrose IVF infusion

Greater Than 1 Month of Age:

Treat for Glucose < 60 mg/dl

- 5 ml/kg of IV D10W (100 mg/ml)

(0.5g/kg) Or

- 2 ml/kg of IV D25W (250

mg/ml)(0.5g/kg)

For Adults (defined age 16 and up) and History of Alcoholism: give 100mg Thiamine IV 50 ml

prior to administration of glucose

If no IV access and child is greater than 2 years of age, may try Oral Therapy with 10-20 grams

of glucose gel.

Hyponatremia: (all age groups)

Treat for Na < 130: give 3% NaCl 2-4 ml/kg IV x 1; may repeat x 1

Hypomagnesemia: (all age groups)

Treat for Mg < 1.5 mg/dl: Give magnesium sulfate 25-50 mg/kg IV over 20 minutes

(maximum 2000 mg)

Hypocalcemia: (all age groups)

Treat for Ca < 7 mg/dl: given 10% Calcium gluconate (100 mg/kg diluted 1:1 with

D5W (given over 5-10 minutes)

Rectal diazepam dosing chart7 :

References:

1. Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, Gottwald MD, O’Neil N,

Neuhaus JM, Segal MR, Lowenstein DH. A comparison of lorazepam, diazepam, and placebo

for the treatment of out-of-hospital status epilepticus. N Engl J Med 2001;345:631–637.

2. Leppik IE, Derivan AT, Homan RW, Walker J, Ramsay RE, Patrick B. Double-blind study

of lorazepam and diazepam in status epilepticus. JAMA 1983;249:1452–1454

3. Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W;

NETT Investigators. Intramuscular versus intravenous therapy for prehospital status

epilepticus. N Engl J Med 2012;366:591– 600.

4. Chamberlain JM, Okada P, Holsti M, Mahajan P, Brown KM, Vance C, Gonzalez V,

Lichenstein R, Stanley R, Brousseau DC, Grubenhoff J, Zemek R, Johnson DW, Clemons TE,

Baren J; Pediatric Emergency Care Applied Research Network (PECARN). Lorazepam vs

diazepam for pediatric status epilepticus: A randomized clinical trial. JAMA 2014;311:1652– 1660.

5. Bleck T, Cock H, Chamberlain J, Cloyd J, Connor J, Elm J, Fountain N, Jones E,

Lowenstein D, Shinnar S, Silbergleit R, Treiman D, Trinka E, Kapur J. The established status

epilepticus trial 2013. Epilepsia 2013;54(suppl 6):89–92

6. Glauser, T, Shinnar S, Gloss D, Alldredge B, Arya R, Bainbridge J, Bare M, Bleck T,

Dodson E, Garrity L, Jagoda A, Lowenstein D, Pellock J, Riviello J, Sloan E, Treiman D.

Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and

Adults: Report of the Guideline Committee of the American Epilepsy Society

7. Diastat AcuDial (package insert). Aliso Viejo, CA: Valeant Pharmaceuticals North America;

2007 (www.diastat.com)

8. Gospe SM Jr. Pyridoxine-Dependent Epilepsy. 2001 Dec 7 [Updated 2017 Apr 13]. In:

Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA):

University of Washington, Seattle; 1993-2018. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK1486/

9. Venkatesan, C., Young, S., Schapiro, M., & Thomas, C. (2017, February). Levetiracetam for

the Treatment of Seizures in Neonatal Hypoxic Ischemic Encephalopathy. Retrieved January

07, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/27872177