Definition (ILAE) (Convulsive SE: **≥5 min** of generalized tonic-clonic activity OR **≥2 seizures** without recovery between · Focal SE without recovery: **≥10 min** — treat as emergency (ILAE 2015, AAP, Child Neurology Society, ERC))
ABCDE & glucose (ABCDE; check glucose immediately — treat hypoglycemia; protect from injury; do not restrain; time seizure onset — **benzodiazepine at 5 min** of convulsive activity (ILAE, AAP, ERC, AHA))
First-line therapy
Midazolam • i.v. • 0.1–0.15 mg/kg/dose • 1×/day
Max 6 mg/dose · Duration: PRN · **0.1–0.2 mg/kg IV** (max **6 mg**/dose) — repeat once in 5 min; slow push; monitor respiration (ILAE, AAP, Child Neurology Society, ERC)
• **Timing:** benzodiazepine at **5 min** of convulsive activity; if seizure continues at **10 min** → second benzodiazepine dose OR proceed to 2nd-line AED; at **20 min** → refractory SE pathway (ILAE, AAP, Child Neurology Society).
• **Glucose:** check immediately — D10 2 mL/kg IV if hypoglycemic; do not delay benzodiazepine for glucose in active convulsive SE if IV access delayed — buccal/IN/IM midazolam first (AAP, ERC).
• **Airway:** position safely; suction PRN; supplemental O₂; intubation if GCS persistently ↓, apnea, or inability to protect airway after seizures — not routine for brief post-ictal sleep (AAP, ERC).
• **Midazolam routes:** IV 0.1–0.2 mg/kg · IM 0.2 mg/kg · buccal/IN 0.2–0.5 mg/kg — all max 10 mg/dose; preferred non-IV routes when no access (ILAE, AAP, ERC).
• **Diazepam:** IV 0.2–0.3 mg/kg (max 10 mg) q5–10 min · rectal 0.5 mg/kg (max 20 mg) — lipophilic, may redose but risk accumulation (ILAE, AAP, ERC).
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Levetiracetam • i.v. • 40–50 mg/kg/dose • 1×/day
Max 4500 mg/dose · Duration: Single load · **40–60 mg/kg IV** (max **4500 mg**) infused over **15 min** — preferred 2nd-line in many protocols; fewer drug interactions (ILAE, AAP, Child Neurology Society)
• **Levetiracetam preferred** when: hepatic disease, mitochondrial disorder, pregnancy adolescent, or valproate contraindicated — 40–60 mg/kg IV over 15 min (ILAE, AAP, Child Neurology Society).
• **Valproate** when: no contraindications and levetiracetam unavailable — avoid in hepatic disease, POLG mutations, urea cycle defects, pregnancy (ILAE, AAP).
• **Phenobarbital** when: neonates or when other 2nd-line agents unavailable — respiratory depression risk with prior benzodiazepines; have airway support ready (ILAE, AAP).
• **PICU consult:** if seizure continues after 2nd-line at 20 min → refractory SE; if hemodynamic instability or need for intubation (AAP, Child Neurology Society, ERC).
• **Investigate cause after stabilization:** infection (meningitis/encephalitis), metabolic, trauma, toxin, electrolyte, new-onset epilepsy — LP/imaging per clinical context (AAP, Child Neurology Society).
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Clinical notes
• Definition: convulsive SE ≥5 min GTC or ≥2 seizures without recovery; focal ≥10 min without recovery (ILAE, AAP).
• ABCDE + glucose check; benzodiazepine at 5 min — midazolam/diazepam/lorazepam; max 2 BDZ doses before 2nd-line (ILAE, AAP, ERC).
• 2nd-line at 10–20 min: levetiracetam 40–60 mg/kg IV, valproate 20–40 mg/kg IV, or phenobarbital 15–20 mg/kg IV (ILAE, Child Neurology Society).
• Intubation if persistent GCS ↓, apnea, or refractory seizures; supplemental O₂ during active seizure (AAP, ERC).
• Investigate underlying cause after stabilization — infection, metabolic, trauma, toxin, electrolyte (AAP, Child Neurology Society).
• ILAE — Classification and treatment of status epilepticus (2015)
• AAP — Pediatric status epilepticus clinical algorithm (2024)
• Child Neurology Society — Pediatric seizure emergency management (2023)
+ 2 more
• ERC — Paediatric convulsive seizure and status epilepticus (2021)
