Treatment Recommendations for Convulsive SE in Children and Adults

0-5 min - Stabilization phase

  1. Stabilize patient (Airway, Breathing, Circulation, Disability), Neurologic examination
  2. Obtain history, time seizure onset, monitor vitals
  3. Asess oxygenation, give oxygen via nasal canula/mask - consider intubation if respiratory assistance is needed
  4. Monitor ECG
  5. Obtain capillary blood glucose. If glucose <60 mg/dl (<3.5 mmol/L):
    • Adults: give 100 mg thiamine IV then 50 ml D50W IV
    • Children ≥2 years: 2 ml/kg D25W IV
    • Childrem <2 years: 4 ml/kg D12.5W IV
  6. Obtain IV access. Collect electrolytes, hematology, toxicology and, if appropriate, AED levels

5-20 min - Initial therapy phase impending SE

Choose one of the following 3 equivalent first line options:

  • IM midazolam 10 mg for >40 kg, 5 mg for 13-40 kg, single dose.
  • IV lorazepam 0.1 mg/kg/dose, max 4 mg/dose, may be repeated once.
  • IV diazepam 0.15-0.2 mg/kg/dose, max 10 mg/dose, may be repeated once.

If none of the above options are available, choose one of the following:

  • IV phenobarbital 15 mg/kg/dose, single dose.
  • Rectal diazepam 0.2-0.5 mg/kg, max 20 mg/dose, single dose.
  • Intranasal or buccal midazolam.

20-40 min - Second therapy phase established SE

There is no evidence based preferred second therapy of choice.

Choose one of the following second line options and give as a single dose:

  • IV fosphenytoin 20 mg PE/kg, max 1500 mg PE/dose, single dose. Infusion rate should not exceed 150 mg PE/minute.
  • IV valproic acid 40 mg/kg, max 3000 mg/dose, single dose. Infusion rate should not exceed 300mg/min.
  • IV levetiracetam 60 mg/kg, max 4500 mg/dose, single dose.

If none of the above are available:

  • Intravenous phenobarbital 15 mg/kg, max dose.

40-60 min - Third therapy phase refractory SE

Threre is no evidence to guide therapy in this phase.

Admission to ICU and continuous EEG monitoring should be established in this phase. Therapeutic options inculde:

  • General anaesthesia with one of:
    • Propofol: loading 2-5 mg/kg, CIV 2-10 mg/kg/h
    • Midazolam: loading 0.2 mg/kg, CIV 0.2-2 mg/kg/h
    • Phenobarbital: loading up to 10 mg/kg ≤25 mg/min, CIV 0.5-2 mg/kg/h
  • Ketamine: bolus 1.5 mg/kg, CIV 0.01-0.05 mg/kg/h
  • Repeat second line of treatment


References

  • Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society Epilepsy Curr. 2016 Jan-Feb; 16(1): 48–61 doi 10.5698/1535-7597-16.1.48