Pediatric Status Epilepticus
Convulsive status epilepticus = a seizure lasting ≥ 5 minutes, or repeated seizures without recovery of consciousness between them. Treat by the clock — outcome worsens the longer it runs. Throughout: airway, high-flow oxygen, position, and a bedside glucose (treat hypoglycaemia first).
Timed algorithm
| Time (from arrival/seizure) | Step |
|---|---|
| 0 min | ABC, O₂, check glucose; note time; IV/IO access |
| 5 min | First benzodiazepine |
| 15 min | Second benzodiazepine (if still fitting); call for senior help; prepare second-line |
| 25 min | Second-line agent infusion |
| 45 min | RSI / thiopental → PICU |
Give no more than two benzodiazepine doses total (including any pre-hospital dose) — a third markedly raises respiratory depression risk.
First line — benzodiazepines
| Drug | Dose | Route | Max |
|---|---|---|---|
| Lorazepam | 0.1 mg/kg | IV/IO | 4 mg/dose |
| Midazolam | 0.3 mg/kg (buccal) / 0.15–0.2 mg/kg IV | buccal / IM / IN / IV | 10 mg/dose |
| Diazepam | 0.5 mg/kg (rectal) / 0.25 mg/kg IV | PR / IV | 10 mg/dose |
If no IV/IO access, use buccal midazolam or rectal diazepam for dose one, then secure access.
Second line
Give if seizure continues after two benzodiazepine doses. Efficacy is broadly similar across agents; levetiracetam and valproate are preferred for ease and safety over phenytoin.
| Drug | Dose | Infusion / cautions |
|---|---|---|
| Levetiracetam | 40 mg/kg (max 2.5 g) | Over 5 min; favourable side-effect profile (APLS/NICE; US ESETT protocol uses 60 mg/kg, max 4.5 g) |
| Phenytoin | 20 mg/kg (max 2 g) | Over 20 min, cardiac monitoring; bradycardia/arrhythmia, hypotension; not if already on phenytoin |
| Sodium valproate | 40 mg/kg (max 3 g) | Avoid in suspected metabolic disease / hepatic dysfunction / <2 y; pregnancy |
(If a child is already maintained on one of these agents, choose a different second-line drug.)
Refractory (after second line)
Proceed to rapid-sequence induction with thiopental (or midazolam/propofol infusion) and intubation under anaesthetic/ICU control. Transfer to PICU.
Don’t forget the reversible causes
Hypoglycaemia, hyponatraemia, hypocalcaemia, fever/sepsis (treat empirically if meningitis/encephalitis suspected), toxins, trauma, and known epilepsy non-adherence. Treat hypoglycaemia with 2 mL/kg of 10% dextrose.
All benzodiazepine and second-line doses are weight-based — confirm weight and check the per-kg figure and cap with the weight-based dose calculator.
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.