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ABCs (Airway, Breathing and circulation) before starting any pharmacologic intervention.
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Place patients in the lateral decubitus position to avoid aspiration of emesis and to prevent epiglottis closure over the glottis.
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Make further adjustments of the head and neck if necessary to improve airway patency.
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Immobilize the cervical spine if trauma is suspected.
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Administer 100% oxygen by facemask.
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Assist ventilation and use artificial airways (eg. endotracheal intubation) as needed.
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Suction secretions and decompress the stomach with a nasogastric tube.
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Maintain normothermia
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Cefotaxime, acyclovir and erythromycin are recommended if aetiology is uncertain and acyclovir should always be used for focal fits of unknown cause
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In the first 5 minutes of seizure activity, try to establish IV access and samples for blood glucose, calcium, magnesium, electrolytes, ABG, CBC, blood culture, etc.
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Send urine for microscopy and toxicology.
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If serum glucose is low or cannot be measured, give children 2 mL/kg of 25% glucose.
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If the seizure fails to stop within 5 minutes, prompt administration of anticonvulsants may be indicated.
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Lorazepam (0.1 mg/kg IV or IO slowly infused over 2-5 min); or diazepam per rectum at 0.5 mg/kg, not to exceed 10 mg
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Phenytoin or fosphenytoin, not to exceed infusion rate of 1 mg/kg/min; if unsuccessful, phenobarbital 10-20 mg/kg IV (not to exceed 700 mg IV); increase
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infusion rate by 100 mg/min; phenobarbital may be used in infants before phenytoin
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Refractor Seizures: Convulsive status epilepticus that is refractory to a benzodiazepine and an appropriate longer-acting anticonvulsant occurs in
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approximately 40% of cases and is associated with higher morbidity and mortality. Please follow the steps below to manage the refractory convulsions.
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Midazolam, loading dose 0.1-0.3 mg/kg IV followed by continuous IV infusion at a rate of 0.1-0.3 mg/kg/h
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Thiopentol anaesthesia (patient already intubated); load by 4 mg/kg and maintain at 1 mg/kg/hr, increase by 1 mg/kg/hr, max 6 mg/kg/hr. Discontinue
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midazolam infusion.
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If difficulty weaning Thiopental, then restart Midazolam infusion during weaning.
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Consider Pyridoxine 100mg IV if under 18 months old.
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Consider urgent CT- Brain, if any suspicion of raised intracranial pressure. If proved, intravenous mannitol should be considered.
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Continuous EEG monitoring can be very helpful particularly to detect non convulsive seizures.
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Do not perform lumbar puncture in the acute state.
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Maintain therapeutic drug levels.
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Continue baseline antiepileptic drugs when possible.
