Breakthrough seizure without ongoing convulsions
›Immediate stabilization and recurrence prevention
›Antiseizure medication re-dosing
›Missed home dose replacement
›Early next scheduled dose if appropriate
›Oral loading or IV loading when indicated
›Levetiracetam IV load for frequent breakthroughs
›Fosphenytoin IV load if phenytoin regimen and low level
›Antiemetic support
›If vomiting prevents oral medication
›If recurrent emesis after dosing
›Trigger-directed correction
›Electrolyte correction
›Infection treatment
Convulsive status epilepticus first-line
›Benzodiazepine therapy
›Lorazepam IV
›Dose 0.1 mg/kg
›Maximum single dose 4 mg
›Repeat once after 5 minutes if ongoing seizure
›Respiratory depression risk
›Airway support readiness
›Continuous monitoring
›Midazolam IM
›Dose 10 mg if weight 40 kg or more
›Dose 5 mg if weight less than 40 kg
›Repeat once after 5-10 minutes if ongoing seizure
›Indications
›No IV access
›Prehospital or immediate ED use
›Diazepam IV
›Dose 0.15-0.2 mg/kg
›Maximum single dose 10 mg
›Repeat once after 5 minutes if ongoing seizure
›Limitations
›Shorter CNS duration than lorazepam
›Early second-line agent planning
Convulsive status epilepticus second-line
›Urgent antiseizure medication loading
›Levetiracetam IV
›Dose 60 mg/kg
›Maximum dose 4500 mg
›Infusion over 10-15 minutes
›Advantages
›Minimal hypotension
›Few drug interactions
›Valproate IV
›Dose 40 mg/kg
›Maximum dose 3000 mg
›Infusion over 10-15 minutes
›Avoid or caution
›Pregnancy
›Severe hepatic disease
›Fosphenytoin IV
›Dose 20 mg PE/kg
›Maximum dose 1500 mg PE
›Infusion rate up to 150 mg PE per minute
›Monitoring
›ECG monitoring
›Blood pressure monitoring
›Phenytoin IV
›Dose 20 mg/kg
›Maximum infusion rate 50 mg per minute
›Hypotension and arrhythmia risk
›Compatibility limitations
›Normal saline only
›In-line filter
Refractory convulsive status epilepticus
›Refractory pathway after benzodiazepine plus second-line failure
›Airway management preparation
›Rapid sequence intubation if needed
›Post-intubation ventilation targets
›Continuous EEG plan
›Early arrangement
›ICU placement planning
›Third-line options and anesthetic infusions
›Midazolam infusion
›Initiate 0.05-0.2 mg/kg/hour
›Titrate by 0.05-0.1 mg/kg/hour every 5-15 minutes
›Typical maximum 2 mg/kg/hour
›Hypotension risk
›Vasopressor readiness
›Fluid responsiveness assessment
›Propofol infusion
›Initiate 20 mcg/kg/min
›Titrate by 10-20 mcg/kg/min every 5 minutes
›Typical maximum 200 mcg/kg/min
›Propofol infusion syndrome risk
›Prolonged high-dose caution
›Metabolic acidosis monitoring
›Ketamine infusion
›Initiate 0.5-1 mg/kg bolus if needed
›Continuous infusion 1-3 mg/kg/hour
›Titrate by 0.5-1 mg/kg/hour to effect
›Advantage
›Less hypotension than GABA-only strategies
›NMDA mechanism for refractory status
›Phenobarbital IV
›Dose 20 mg/kg
›Infusion rate 50-100 mg per minute
›Additional 5-10 mg/kg if needed
›Respiratory depression risk
›Intubation threshold lower
›ICU monitoring requirement
Trigger-directed therapies
›Correctable cause management
›Hypoglycemia
›Dextrose IV
›D10W 250 mL adult dose option
›Repeat based on glucose recheck
›Thiamine
›If malnutrition or alcohol use disorder
›If Wernicke risk
›Hyponatremia
›Hypertonic saline if severe symptoms
›3% saline 100 mL bolus
›Repeat up to 2 additional boluses for ongoing severe symptoms
›Correction rate caution
›Avoid rapid overcorrection
›Frequent sodium checks
›Eclampsia
›Magnesium sulfate
›Loading 4-6 g IV over 15-20 minutes
›Maintenance 1-2 g/hour infusion
›Blood pressure control
›Labetalol IV per protocol
›Hydralazine IV per protocol
›Alcohol withdrawal
›Benzodiazepine protocol
›Symptom-triggered dosing
›Adjunct phenobarbital in select cases