#EMconf: Meds for the Seizing Patient

Medications for the Seizing Patient

First line:
-IM Midazolam (if > 40 kg → 10mg IM, if 13-40 kg → 5mg IM)
-IV lorazepam ( IV 0.1 mg/kg, max dose 4 mg)
-IV diazepam (IV 0.2 mg/kg, max 10mg)

If none of the above are available:
-IV Phenobarbital (20 mg/kg, at 50mg/min, be prepared to intubate)
-PR Diazepam (0.5 mg/kg, max 20 mg/dose)
-IN Midazolam (0.2 mg/kg, max of 6 mg) or Buccal Midazolam (0.3 mg/kg, max of 10mg)

Second Line: *There is no clear evidence that any one of these options is better than others. Choose one and give as a single dose 
-IV Fosphenytoin (20 mg PE/kg, max 1500 mg PE/dose)
-IV Valproic Acid (40 mg/kg, max 3000 mg/dose)
-IV Levetiracetam (60 mg/kg, max 4500 mg/dose
-IV Phenobarbital ( 15-20 mg/kg, Level B) → Avoided due to adverse effects


Third Line: *There is no clear evidence to guide this phase 
-Repeat second line options
-Anesthetic doses of: Midazolam (0.2 mg/kg, then infusion of 0.05-2mg/kg/hr) Propofol (2-5 mg/kg, then infusion of 2-10 mg/kg/hr) Ketamine (loading 0.5- 3 mg/kg, followed by infusion) Thiopental or Pentobarbital
-Consider anesthesia consult for inhaled anesthetics (potent anticonvulsants)
*All with continuous EEG monitoring


Source: Glauser, T., Shinnar, S., Gloss, D., Alldredge, B., Arya, R., Bainbridge, J., & ... Treiman, D. M. (2016). Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Currents, 16(1), 48-61.