View source for Template:Initial management of pediatric status epilepticus

===Initial management of [[pediatric status epilepticus]]===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Timeline'''
| align="center" style="background:#f0f0f0;"|'''General Considerations'''
| align="center" style="background:#f0f0f0;"|'''Seizure Treatment'''
|-
| 0-5 minutes
||
*Supportive care 
** ABC's
** Maintain airway; suction, jaw thrust
** Provide [[O2]] via positive pressure ventilation with BVM/Mapleson
***Likely apneic/hypoventilating/hypercapneic
***Only apply CPAP or a non-rebreather if patient stops seizing and has adequate chest rise
*Establish IV/[[IO]] access 
*Check blood glucose 
*If fever, [[acetaminophen]] 15 mg/kg rectally
||
*'''Benzodiazepine: first dose''' 
**IV/IO access established 
***[[Lorazepam]] 0.1 mg/kg IV (max 4 mg) if IV/IO access, OR 
***[[Diazepam]] 0.2 mg/kg IM (max 10 mg) if no access 
**IV or IO access not achieved within 3 minutes: 
***Buccal [[midazolam]] 0.2 mg/kg (max 10 mg), OR 
***IM  [[midazolam]] 0.2 mg/kg (max 10 mg), OR 
***Rectal [[diazepam]] (Diastat gel or injection solution given rectally) 0.5 mg/kg (max 20 mg) 
|-
| 5-10 minutes
||
*Give antibiotics if concern for [[sepsis]] or [[meningitis]] 
*POC electrolytes, if available
||
*'''Benzodiazepine: second dose'''
|-
| 10-15 minutes
||
*All equally efficacious for status epilepticus
*Levetiracetam is preferred given quick administration, favorable side effect profile, and less drug interactions
*Do not combine Phenytoin and Fosphenytoin
||
*'''Antiepileptic: first therapy''' 
**[[Levetiracetam]] 60 mg/kg IV/IO (max 4500mg) over 5 min, OR 
**[[Fosphenytoin]]^ 20 mg PE/kg IV/IO (max 1500mg) over 10 min, OR 
**[[Valproate]]  40 mg/kg IV/IO (max 3000mg) over 10 min, OR 
**[[Phenobarbital]] 20 mg/kg IV/IO, (max 1 g) over 20 min, (expect respiratory depression with apnea)¥ 
|-
| 15-30 minutes
||
*Consider intubation, if not already performed
**Consider NG tube to decompress stomach prior to intubation
*Pediatric neurology consultation
||
*'''Antiepileptic: second therapy''' (if medication not already given)
**[[Fosphenytoin]]^ 20 mg PE/kg IV/IO (max 1500mg) over 10 min, OR 
**[[Valproate]] 40 mg/kg IV/IO (max 3000mg) over 10 min, OR
**[[Phenobarbital]] 20 mg/kg IV/IO (max 1 g) over 20 min 
***10 mg/kg if phenobarbital already given, OR 
**[[Levetiracetam]] 60 mg/kg IV/IO (max 4500mg) over 5 min 
*If [[isoniazid toxicity]] suspected, [[pyridoxine]] 
**Infants (<1 year): 100 mg IV or IO in 
**Otherwise 70 mg/kg IV or IO (max = 5 g)
|-
| >30 minutes
||
*Intubate patient, if not already performed
*Consult referral site / PICU for admission and continuous EEG
||
*'''Antiepileptic: third therapy'''
**Midazolam 0.2mg/kg IV bolus (max 10mg), followed by 0.2mg/kg/hr (max 10mg/hr) infusion drip
**Increase infusion rate by 0.2mg/kg/hr (max 10mg/hr) every 10 minutes until burst suppression or max dose of 2mg/kg/hr (max 100mg/hr)
|}
^May be ineffective for toxin-induced seizures and contraindicated in [[cocaine toxicity]]