2012 - 2013 Acute Seizure Management Guideline Children >1 month old Use as recommendation, not to replace clinical judgment
Medication management *Benzodiazepine Options IV access—Midazolam (Versed) 0.2 mg/kg/dose (max 10 mg/ Option 2: Diazepam (Valium) 0.5 mg/kg/dose (max 20m g/dose) dose) IV undiluted over 2 minutes Rectal administration (if no Diastat, use undiluted diazepam IV No IV access product PR) Option 3: Lorazepam (Ativan) 0.1 mg/kg/dose (max 4 mg/dose) Option 1: Midazolam 0.3 mg/kg/dose (max 10 mg/dose) Buccal administration (instill IV product between teeth and cheek) IM x 1 undiluted over 2 minutes
**Antiepileptic Options Option 1: If Fosphenytoin is not available, use Phenytoin (Dilantin) Option 2: Consider Valproic Acid (Depakote) 25 mg/kg/dose IV 20 mg/kg/dose diluted 1:1 with NS IV x 1 over 15 minutes (watch diluted 1:1 with NS over 9 minutes for hypotension, tachycardia, bradycardia and (Valproic Acid should be considered as first choice if patient is extravasation which can cause severe necrosis) on Valproic Acid and is suspected of being noncompliant)
Option 3: Lacosamide (Vimpat) 1 mg/kg/dose (max 50mg) IV undiluted over 60 minutes (Use as first line therapy for nonconvulsive status)
***Medication Induced Coma Options Option 1: Pentobarbital 15 mg/kg/dose bolus IV undiluted over at Option 2: Propofol 3 mg/kg bolus then start infusion at 1 mg/kg/ least 10 minutes then start infusion 0.5 mg/kg/hr, increase to 10 hr. Bolus may only be administered by an attending. mg/kg/hr (Only when previous infusions have failed should a short term infusion of Propofol be initiated due to Propofol Infusion Syn- drome—hypotension, lipidemia, and metabolic acidosis. Never use Propofol if Phenytoin has been used).
1 PATIENT PRESENTS IN STATUS EPILEPTICUS ■■ Administer oxygen and/or provide air way maneuvers to assist ■■ Administer antiepileptic medication per guideline ventilation ■■ Obtain serum chemistries, hematology studies, toxicology ■■ Monitor vital signs and perform Advanced Life Support as needed screens, and antiepileptic medication levels if appropriate ■■ Give dextrose if finger stick reveals glucose <80 (refer to ■■ Verify medication allergies glucose parameters on second sheet)
SEIZURE >5 MINUTES
INTRAVENOUS OR ALTERNATIVE MEDICATIONS ON BACK NO IV/IO LINE INTRAOSEOUS LINE
*Midazolam (Versed) 0.3 mg/kg/dose *Lorazepam (Ativan) 0.1 mg/kg/dose Max 10 mg/dose Buccal administration Max 4 mg/dose IV/IO over 2 minutes (instill IV product between teeth and cheek)
MAY REPEAT BENZODIAZEPINE X 1 AFTER 5 MINUTES IF SEIZURE CONTINUES
*Midazolam (Versed) 0.3 mg/kg/dose *Lorazepam (Ativan) 0.1 mg/kg/dose Max 10 mg/dose Buccal administration Max 4 mg/dose IV/IO over 2 minutes (instill IV product between teeth and cheek)
IF PATIENT HAS LIVER DISEASE, METABOLIC DISEASE, OR COAGULOPATHY SKIP TO KEPPRA
Fosphenytoin must be diluted in **Fosphenytoin (Cerebyx) 20 mg/kg/dose In absence of IV access, give an equal amount of NS for IV/IO Max 1000 mg/dose IV/IO over 7 minutes Fosphenytoin intramuscularly, and IM administration WATCH FOR HYPOTENSION AND CARDIAC DYSFUNCTION but poor peripheral circulation may compromise absorption.
IF SEIZURE PERSISTS AFTER COMPLETION OF INFUSION
**Fosphenytoin 10 mg/kg/dose IV/IO over 3 minutes
IF SEIZURE PERSISTS AFTER 20 MINUTES FROM INITIATION OF INFUSION
**Levetiracetam (Keppra) 30 mg/kg/dose IV/IO x 1 over 6 minutes
Leveitracetam must be diluted in an equal amount of NS for IV/IO administration
IF SEIZURE PERSISTS, TRANSFER TO PICU FOR MEDICATION INDUCED COMA
***Midazolam 0.2 mg/kg bolus over 2 minutes Then start infusion at 0.05 mg/kg/hr use 1 mg/mL in NS concentration Increase by 0.01 mg/kg/hr every 5 minutes until seizure subsides or reach 2 mg/kg/hr
2 SPECIFIC CONDITIONS
Hypoglycemia Dextrose For peripheral line administration ■■ 0.5 to 1 gram/kg/dose ■■ Dilute D25W with equal amount NS or ■■ 2 to 4 mL/kg/dose D25W SWFI to make D12.5W
For central line administration ■■ May administer undiluted D25W Hyponatremia Hypertonic saline should only be given in an intensive care setting (PICU, ED). Please consult critical care attending. Hyperthermia Monitor core temperature and maintain normothermia
Medication 2.5 kg 5 kg 7.5 kg 10 kg 15 kg 20 kg 30 kg 40 kg 50 kg Bolus Lorazepam 0.25mg 0.5mg 0.75mg 1 mg 1.5 mg 2 mg 3 mg 4 mg 4 mg Fosphenytoin 50 mg 100mg 150mg 200mg 300mg 400mg 600mg 800 mg 1000 mg Midazolam 0.5mg 1 mg 1.5 mg 2 mg 3 mg 4 mg 6 mg 8 mg 10 mg Keppra 75 mg 150mg 225mg 300mg 450mg 600mg 900mg 100 mg 1000 mg Phenytoin 50 mg 100mg 150mg 200mg 300mg 400mg 600mg 800 mg 1000 mg Valproic Acid 65 mg 125mg 200mg 250mg 375mg 500mg 750mg 1000 mg 1000 mg Pentobarbital 40 mg 75 mg 115mg 150mg 225mg 300mg 450mg 600 mg 750 mg Propofol 7.5 mg 15 mg 25 mg 30 mg 45 mg 60 mg 90 mg 120 mg 150 mg
Disclosure: Practice guidelines do not necessarily apply to every patient. A provider’s clinical judgment is essential. As always, clinicians are urged to document management strategies. Floating Hospital for Children at Tufts Medical Center contact: Anthony Rodrigues, M.D., Ph.D., Dan Hale, M.D. ([email protected])
3 Update 030315 | 15-0028 PD-HS