Code Duration
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Enter age to auto-select pathway · defaults to Infant / Child (ESETT)
Notes
Stat — Do First
  • POC glucoseif low: D10 2 mL/kg (neonate) · D25 2–4 mL/kg (infant/child)
  • IV access ×2 — IO if nonedon't delay meds for access
  • VBG
Labs
  • CBC · CMP · Mg · Phos · iCal · ammonia · lactate
  • Blood cultures ×2if febrile / sepsis concern
  • Tox screenif ingestion possible
Case-Specific
  • ASM levelsif on antiseizure meds
  • IEM screen — plasma AA, urine organic acids, acylcarnitineneonate / suspected metabolic
  • Send CSF AASA before empiric pyridoxinepyridoxine-dependent epilepsy — neonate/infant
  • CSF + plasma glucose (GLUT1)unexplained infantile seizures
Infant < 6–12 weeks
  • LP incl. CSF HSV PCRsepsis / meningitis eval — any seizure ± fever
  • Start antibiotics + IV acyclovir if LP sentcomplete the work-up once started
  • Consider NAT — skeletal survey / dilated examinfant, unexplained
Imaging
  • Head CT (acute) / MRInew focal seizure or prolonged encephalopathy
Other
  • ECGbefore Na-channel agents (fosphenytoin, lacosamide)
  • EEG — page techs 34886 + epilepsy 60972rule out non-convulsive status
On-Call Contacts
Pediatric Neurology — on call
Call for any seizure code · placeholder link — set your paging URL
→
PICU — on call
Phase 3 / refractory — ICU, intubation · placeholder link
→
EEG techs
Page to connect continuous EEG
34886
Epilepsy fellow / attending
Notify of incoming LTM order
60972
UMich paging portal
Look up any on-call service
→
RSI — Rapid Sequence Intubation
After RSI: paralysis masks seizure activity — get cEEG ASAP. Patient may still be actively seizing without motor signs.
Induction Agent
Ketamine (preferred in status epilepticus)
1.5–2 mg/kg IV
Antiseizure properties + hemodynamically supportive. NMDA antagonist.
Etomidate
0.3 mg/kg IV
Hemodynamically neutral. Single RSI dose acceptable — avoid infusion (adrenal suppression).
Propofol
1–2 mg/kg IV
Also antiseizure; watch for hypotension — titrate carefully.
Paralytic
Rocuronium (preferred)
1.2 mg/kg IV
Duration ~60 min. Reverse with sugammadex 16 mg/kg IV if needed.
Succinylcholine — AVOID
1.5 mg/kg IV
Only 8–12 min paralysis — short duration masks ongoing seizure. Use only if rocuronium unavailable.
Post-Intubation Sedation (antiseizure)
Propofol infusion
20–200 mcg/kg/min
Titrate to burst suppression on cEEG. Monitor for PRIS >48h.
Ketamine infusion
0.3–7.5 mg/kg/hr
NMDA antagonist; preferred if hemodynamically unstable. Can combine with propofol.
Midazolam infusion
0.05–2 mg/kg/hr
Add analgesic. Tolerance develops with prolonged use.
Timing Overview — Infant / Child ▼
All doses are weight-based. Enter weight on the Timers tab to see mg. Standard ESETT / NCS pediatric pathway.
0 minStart timer — ABCs, IV/IO access ×2, POC glucose, O₂Page pediatric neurology now
0–5 minPhase 1, Dose 1 — Lorazepam 0.1 mg/kg IV (max 4 mg) or Midazolam 0.2 mg/kg IM/IN (max 10 mg) if no IVIM/IN midazolam ≈ IV lorazepam in efficacy (RAMPART)
5 minStill seizing → Phase 1, Dose 2 — repeat benzo (max 2 doses total)
20 minStill seizing → Phase 2 — Levetiracetam 60 mg/kg (max 4,500) or Fosphenytoin 20 PE/kg (max 1,500) or Valproate 40 mg/kg (max 3,000)ESETT: agents equivalent. Valproate contraindicated < 4 yr / mitochondrial disease
30–40 minStill seizing → Refractory Status (Phase 3)PICU, intubate, anesthetic infusion (ketamine / midazolam / pentobarbital), continuous EEG
Airway ▼
  • ·Recovery position (left lateral decubent) — reduces aspiration risk during active seizure
  • ·Suction secretions and vomitus immediately
  • ·NPA preferred over OPA — jaw clenching makes OPA placement dangerous; NPA tolerated in semi-conscious patients
  • ·Prepare for intubation early if any of the following:
    • SpO₂ < 90% despite high-flow O₂
    • Unable to maintain/protect airway
    • Phase 3 / anesthetic infusion planned
    • Phenobarbital load anticipated
  • ·RSI agent preference:
    • Ketamine 1.5–2 mg/kg IV — preferred; antiseizure properties + hemodynamically supportive
    • Propofol 1–2 mg/kg IV — also antiseizure; watch hypotension
    • Avoid succinylcholine — short paralysis masks ongoing seizure activity; use Rocuronium 1.2 mg/kg
  • ·Paralysis ≠ seizure cessation — get EEG ASAP after RSI; patient may still be seizing without motor signs
Breathing & Oxygenation ▼
  • ·High-flow O₂ via NRB 10–15 L/min immediately; target SpO₂ ≥ 94%
  • ·Benzodiazepines cause respiratory depression — BVM must be at bedside before giving any dose
  • ·Monitor RR and work of breathing continuously; be ready to assist
  • ·If intubated: target ETCO₂ 35–45 mmHg; avoid hyperventilation (cerebral vasoconstriction worsens ischemia)
Circulation ▼
  • ·2 large-bore IVs (AC or above) stat — IO is acceptable if no IV; do not delay medications for IV access
  • ·Continuous cardiac monitoring throughout; 12-lead ECG before Phase 2 agents
  • ·Hypertension during/postictal is common and usually self-limiting — treat only if MAP >130 or SBP >200
  • ·Hypotension — aggressive IV fluids + vasopressors; suspect underlying cause; secondary brain injury from hypotension is devastating
  • ·Drug-specific cardiac considerations:
    • Fosphenytoin: infuse ≤ 150 PE/min; cardiac monitor mandatory; risk of hypotension, bradycardia, QT prolongation
    • Valproic acid: infuse ≤ 3–6 mg/kg/min; avoid in liver failure, suspected mitochondrial disease
    • Lacosamide: may prolong PR interval; caution with known conduction disease
Temperature ▼
Hyperthermia dramatically worsens neuronal excitotoxicity — treat aggressively
  • ·Hyperthermia is common from sustained motor activity + impaired thermoregulation — check core temp early
  • ·Cool aggressively if T > 38.5°C:
    • Ice packs to axillae, groin, and neck
    • Cooling blanket
    • Cool IV fluids
  • ·Rectal or esophageal temp preferred over axillary for accuracy
Metabolic Corrections ▼
  • ·Hypoglycemia (BG < 60): D10W 2 mL/kg (neonate) or D25W 2–4 mL/kg (infant/child) IV; recheck q15 minavoid D50 in young children — too hyperosmolar
  • ·Hyponatremia (Na < 120 or rapid fall): 3% NaCl 3–5 mL/kg IV over 15–20 min; contact neurology; target Na rise ≤ 8–10 mEq/L per 24h
  • ·Hypomagnesemia: MgSO₄ 25–50 mg/kg IV over 10–20 min
  • ·Hypocalcemia (iCa < 1.0): Ca gluconate 50–100 mg/kg IV over 10–20 min (cardiac monitor)
  • ·Pyridoxine (B6): in a neonate/infant with refractory seizures, trial 100 mg IV watching EEG — send CSF AASA first
  • ·Post-seizure lactic acidosis is expected from muscle activity — do not over-interpret VBG pH; typically clears within 60 min
Phase 3 — Refractory Status (RSE) ▼
Defined as: seizure > 30–40 min OR failure of ≥ 2 antiseizure meds — PICU admission required
  • ·Continuous EEG monitoring mandatory — goal is burst suppression pattern
  • ·Intubate before starting anesthetic infusions in most cases
  • ·Anesthetic infusion options (titrate to burst suppression on EEG):
    • Ketamine (UMich): 2–3 mg/kg IV ×2 (5 min apart) → 1 mg/kg/hr, titrate ≤0.6 mg/kg/hr q10 min → max 3.6 (abs 7.5) mg/kg/hr — preferred if hemodynamically unstable
    • Midazolam: 0.2 mg/kg IV bolus → 50 mcg/kg/hr, ↑ 40–60 → max 400–1000 mcg/kg/hr
    • Pentobarbital: 5 mg/kg IV bolus → 0.5–1 mg/kg/hr → max 3 mg/kg/hr (bradycardia, hypotension, ileus)
    • Propofol: 1–2 mg/kg IV bolus → 20–200 mcg/kg/min; PRIS risk — caution in young children, >48h or >4 mg/kg/hr
    • Lidocaine (neonate): 2 mg/kg over 10 min → 6→4→2 mg/kg/hr taper; not if prior phenytoin or cardiac disorder
    • Phenobarbital: 20–30 mg/kg IV — first-line in neonates; can precede anesthetic agents
  • ·Pediatric neurology / PICU consultation mandatory at this stage
Safety & Positioning ▼
  • ·Lower the bed, raise and pad side rails
  • ·Do NOT restrain — guide and protect from injury only
  • ·Nothing in the mouth — never forcibly insert anything; broken teeth and gloves are aspiration risks
  • ·Remove hard/sharp objects from immediate environment; push away furniture
  • ·Minimum two people at bedside during active convulsion
  • ·Document seizure onset time, character, and duration — this is medicolegally and clinically important
Clinical Pearls & Pitfalls ▼
Evidence base: AAN 2016 Guideline, Neurocritical Care Society CSE Protocol, RAMPART trial (NEJM 2012), ESETT trial (NEJM 2019)
  • ·IM midazolam 10 mg = IV lorazepam in efficacy and time-to-abort seizure (RAMPART 2012) — use IM if no IV access
  • ·Intranasal midazolam 5 mg/nostril is a bridge option if no IV or IM access available
  • ·Non-convulsive status epilepticus (NCSE) occurs in 20–48% of patients after apparent motor cessation — do not stop monitoring; get EEG
  • ·Phenytoin (not fosphenytoin) is not recommended for acute SE — inferior efficacy confirmed in ESETT trial + cardiotoxic
  • ·ESETT trial showed Keppra, fosphenytoin, and valproate have similar efficacy (~50%) as Phase 2 agents — Keppra preferred due to availability and safety profile
  • ·Eclampsia: MgSO₄ 4g IV over 15 min is first-line — not benzos as primary therapy
  • ·Alcohol withdrawal seizures: benzos are definitive treatment; phenytoin is ineffective
  • ·Pregnancy: lorazepam and fosphenytoin are acceptable; valproate contraindicated
  • ·Seizure-related hypertension is usually self-resolving — do not over-treat; hypotension causes secondary brain injury
  • ·Lorazepam has longer CNS duration of action than diazepam — preferred for acute SE when IV access available
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