›Immediate stabilization
›If ongoing convulsions then time from onset
›If SpO2 less than 92 percent then oxygen
›If inadequate ventilation then bag mask ventilation
›If refractory hypoxia then prepare intubation
›Cardiac monitor
›Two IV lines or IO
›Point of care glucose
›If glucose low then dextrose per local protocol
Convulsive status epilepticus algorithm
›Medication sequence adult typical pathway local protocol dependent
›First line benzodiazepine
›Lorazepam IV 0.1 mg per kg
›Maximum single dose 4 mg
›May repeat once after 5 to 10 minutes
›Midazolam IM 10 mg if no IV access
›Midazolam intranasal 0.2 mg per kg option
›Second line antiseizure load
›Levetiracetam IV 60 mg per kg
›Maximum 4500 mg
›Fosphenytoin IV 20 mg PE per kg
›Maximum 1500 mg PE
›Valproate IV 40 mg per kg
›Maximum 3000 mg
›If ongoing seizures after second line then ICU pathway
›Intubation and anesthetic infusion
›Midazolam infusion titration local protocol dependent
›Propofol infusion titration local protocol dependent
›Continuous EEG if available
Pediatric dosing highlights
›Pediatric convulsive status local protocol dependent
›Lorazepam IV 0.1 mg per kg
›Midazolam IM 0.2 mg per kg
›Levetiracetam IV 40 to 60 mg per kg
Cause directed treatments
›Reversible causes
›If eclampsia concern then magnesium sulfate per obstetric protocol
›If suspected meningitis then antibiotics after cultures and early dexamethasone when indicated
›If suspected encephalitis then acyclovir early
›If alcohol withdrawal then benzodiazepine regimen and thiamine
›If isoniazid toxicity then pyridoxine per toxicology guidance
Monitoring and reassessment loop
›Reassessment cycle
›Neuro status every 15 to 30 minutes until baseline
›Airway and ventilation after each sedating dose
›Temperature management if hyperthermia
›CK and renal function monitoring if prolonged convulsions
›Consultation triggers
›Neurology for first unprovoked seizure with abnormal exam
›Neurology for recurrent seizures despite treatment
›Critical care for refractory seizures or airway risk
›Obstetrics for pregnancy related seizures
›Toxicology for suspected ingestion or withdrawal