Status epilepticus (SE) is a medical emergency consisting of persistent or recurring seizures without a return to baseline mental status. SE is not a single entity, but can be divided into subtypes based on seizure types and underlying etiologies. Management should be implemented rapidly and based on continuously reassessed care pathways.

The aim is to terminate seizures while simultaneously identifying and managing precipitant conditions. Seizure management involves “emergent” treatment with benzodiazepines (lorazepam intravenously, midazolam intramuscularly, or diazepam rectally) followed by “urgent” therapy (phenytoin/fosphenytoin, phenobarbital, levetiracetam or valproate sodium). If seizures persist, “refractory” treatments include infusions of midazolam or pentobarbital.

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Prognosis is dependent on the underlying etiology and seizure persistence. This paper reviews the current management options and strategies for pediatric convulsive status epilepticus. Introduction The most recent Neurocritical Care Society guideline for status epilepticus (SE) management in children and adults defines SE as “5 minutes or more of (i) continuous clinical and/or electrographic seizure activity or (ii) recurrent seizure activity without recovery (returning to baseline) between seizures.”[] Refractory status epilepticus (RSE) is defined as clinical or electrographic seizures which persist after an adequate dose of an initial benzodiazepine and a second appropriate anti-seizure medication. Overall Management Approach Initial SE management should involve resuscitation and an evaluation to identify any acute symptomatic SE etiologies.[, ] The Neurocritical Care Society guideline provides a critical care treatment outline. These steps include non-invasive airway protection and gas exchange with head positioning (0–2 minutes), intubation if airway or gas exchange is compromised or intracranial pressure is elevated (0–10 minutes), vital signs assessment (0–2 minutes), vasopressor support if needed (5–15 minutes), neurologic examination (0–5 minutes), and placement of peripheral intravenous access for administration of emergent anti-seizure medication therapy and fluid resuscitation (0–5 minutes). Initial etiologic testing should include bedside finger stick blood glucose (0–2 minutes), and lab testing including blood glucose, complete blood count, basic metabolic panel, calcium, magnesium, and anti-seizure medication levels (5 minutes). Benzodiazepines Benzodiazepines are the emergent medications of choice, with specific benzodiazepines determined by the available route of administration; lorazepam for intravenous administration, midazolam for intramuscular or intranasal administration, and diazepam for rectal administration.[] Repeat dosing may be provided in 5–10 minutes if needed.

However, care should be taken to assess whether any pre-hospital benzodiazepines were administered in which case progressing to the next urgent medication may be indicated. Lorazepam may be administered intravenously at 0.1mg/kg with a repeat dose in 5 minutes, up to a maximum dose of 4mg. Diazepam may be administered intravenously at 0.15mg/kg with a repeat dose in 5 minutes, up to a maximum dose of 10mg.

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