1. Stabilize (Airway, Breathing, Circulation)

2. Begin timer, monitor vital signs

3. Assess oxygenation - provide supplemental O2 or consider intubation if necessary

4. Initiate EKG monitoring

5. Collect fingerstick glucose, if < 60 mg/dL

   • adults: given 100 mg thiamine IV, then 50 mL 50% dextrose (1 amp of D50) IV

   • children ≥ 2 years: 2 mL/kg 25% dextrose IV

6. Attempt IV access and collect CBC, BMP, toxicology screen, anti-seizure medication levels (if relevant)

**it is OK to treat prior to 5 min**

• First-line = Benzodiazepine, choice of

  1. Lorazepam (Ativan) IV 0.1 mg/kg/dose, max 4 mg/dose

     • may repeat dose once

  2. Diazepam (Valium) IV 0.2 mg/kg/dose, max 10 mg/dose

     • or per rectum 0.2-0.5 mg/kg/dose, max 20 mg/dose

     • may repeat dose once

  3. Midazolam (Versed) IV or IM

     • 10 mg for pt weight > 40 kg

     • 5 mg for pt weight 13-40 kg

     • do not repeat dose

• Second-line medications

• Send free and total medication levels 1 hour after completing dose

  1. Levetiracetam (Keppra) IV 60 mg/kg, max 4500 mg/dose

     • loading dose does not require renal adjustment

  2. Valproic Acid (Depakote) IV 40 mg/kg, max 3000 mg/dose

     • excellent option if patient is hypotensive

     • caution in liver disease or women who may be pregnant

     • repeat 20 mg/kg bolus if seizures continue

  3. Fosphenytoin (Cerebryx) IV 20 mg PE/kg, max 1500 mg/dose

     • requires BP and EKG monitoring - decrease infusion rate if hypotensive

     • may administer IM if no IV access

     • repeat 10 mg PE/kg if seizures continue

• Alternative Options:

  1. Lacosamide (Vimpat) IV 400 mg

  2. Phenytoin (Dilantin) IV 20 mg/kg

     • avoid if fosphenytoin is available as phenytoin results in hypotension and can cause tissue necrosis (purple glove syndrome)

Intubate if not already done

• AVOID depolarizing neuromuscular blockade (e.g. succinylcholine)

Connect EEG if not already done

• Choice of

  1. Midazolam (Versed) 0.2 mg/kg bolus followed by 0.1 mg/kg/hr infusion

  2. Propofol 5-80 mcg/kg/min

     • Avoid bolus unless you are prepared to correct hypotension with pressors

     • several status algorithms allow higher dosing (up to 400 mcg/kg/min)

  3. Phenobarbital/Pentobarbital 10-20 mg/kg bolus followed by 0.5 mg/kg/hr infusion

• Drips should be titrated either to seizure-suppression or burst-suppression, guided by EEG monitoring