Paediatrics & Child Health, 2021, 50–57

doi: 10.1093/pch/pxaa127
Position Statement

Position Statement

Emergency management of the paediatric patient with

convulsive status epilepticus
Kyle C. McKenzie, Cecil D. Hahn, Jeremy N. Friedman
Canadian Paediatric Society, Acute Care Committee, Ottawa, Ontario
Correspondence: Canadian Paediatric Society, 100–2305 St Laurent Blvd, Ottawa, Ontario K1G 4J8. E-mail info@cps.ca,
website www.cps.ca

All Canadian Paediatric Society position statements and practice points are reviewed regularly and revised as needed.
Consult the Position Statements section of the CPS website www.cps.ca/en/documents for the most current version.
Retired statements are removed from the website.

Abstract
This guideline addresses the emergency management of convulsive status epilepticus (CSE) in child-
ren and infants older than 1 month of age. It replaces a previous position statement from 2011, and
includes a new treatment algorithm and table of recommended medications based on new evidence
and reflecting the evolution of clinical practice over the past several years. This statement emphasizes
the importance of timely pharmacological management of CSE, and includes some guidance for dia-
gnostic approach and supportive care.

Keywords: Convulsions; Emergency management; Paediatrics; Seizures; Status epilepticus

An algorithm on managing status epilepticus is available as a supplementary figure online.

BACKGROUND AND EPIDEMIOLOGY neurological deficits, persisting cognitive impairment, and

The conventional definition of convulsive status epilepticus behaviour problems) of between 10% and 20% (2).
(CSE) is continuous generalized tonic-clonic seizure activity This statement addresses CSE in children and infants older
with loss of consciousness for longer than 30 minutes, or two than 1 month of age.
or more discrete seizures without a return to baseline mental
status (1). Additionally, the terms “early” or “impending” sta- PROTOCOLS AND GUIDELINES
tus epilepticus have been defined as continuous or intermittent There is limited evidence in paediatrics on which to base a “gold
seizures lasting longer than 5 minutes without full recovery of standard” protocol for the management of CSE. Many different
consciousness between seizures. Research has shown that early guidelines currently in use are based on varying combinations
treatment is more effective in stopping such seizures, while treat- of evidence, consensus opinion, local experience, and drug avai-
ment delay results in increased morbidity and mortality (2,3). lability (2–16). Despite minor variations in detail, these guide-
The annual incidence of CSE in children is reported as 10 to lines are similar in many ways.
73 episodes/100,000 children and is highest in children youn- Status epilepticus is a medical emergency requiring prompt,
ger than 2 years of age (4). Common etiologies are listed in definitive management. Although the outcome of status epilep-
Table 1. Mortality has been reported to be between 2.7% and ticus is mainly determined by its cause, the duration of CSE is
8%, with an overall morbidity (including newly diagnosed neu- also important. A timely approach may be more important than
rological disorders, hemodynamic instability, long-term focal specific pharmacological intervention.

Received: July 22, 2019; Accepted: June 8, 2020

© Canadian Paediatric Society 2021. Published by Oxford University Press on behalf of the Canadian Paediatric Society. 50
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
Paediatrics & Child Health, 2021, Vol. 26, No. 1 51

Table 1. Common etiologies of convulsive status epilepticus in and an immediate need to establish the airway and ventilate
children the patient, either by bag-valve-mask ventilation or intubation.
Acute pathology Intravenous (IV) access should be obtained as soon as possible
(two large-bore IV lines, if possible).
• Acute symptomatic A bedside blood glucose level should be obtained.
◦ Acute central nervous system infection (meningitis or
encephalitis) Terminate the seizure and prevent recurrence
◦ Anoxic injury Principles of treatment and monitoring
◦ Metabolic derangement (hypoglycemia, hypergly- The main goal of treatment is to stop the seizure and, in doing
cemia, hyponatremia, hypocalcemia) so, prevent brain injury (3,15). Use of medications to terminate
◦ Traumatic injury the seizure should be considered for seizures lasting longer than
◦ Drug-related 5 to 10 minutes. When administering medications, obtain IV
• Antiepileptic drug noncompliance or access as soon as possible.
withdrawal A brief history and focused physical exam should be perfor-
• Antiepileptic drug overdose med. Pay particular attention to any history of seizure disorder,
• Nonantiepileptic drug overdose other symptoms (e.g., fever), medication usage, and allergies to
• Prolonged febrile convulsion medications.
Remote pathology A bedside glucose test will establish the need for a bolus of
dextrose. If the blood glucose (BG) level is ≤2.6 mmol/L, the
• Cerebral dysgenesis recommended management is a bolus of 0.5 g/kg of dextrose.
• Perinatal hypoxic–ischemic encephalopathy Administer 2 mL/kg of 25% dextrose water (D25W) via central
• Progressive neurodegenerative disorders line, or 5 mL/kg of 10% dextrose water (D10W) by periphe-
• Prior brain injury (meningitis, stroke, trauma) ral IV. When the patient is hypoglycemic, BG level should be
Idiopathic/cryptogenic rechecked 3 to 5 minutes post-bolus, and a repeat bolus admi-
nistered if necessary.
Adapted from reference (4). If IV access is unavailable, then other routes should be
used while efforts to establish vascular access continue.
The objectives in acute management of CSE are to: Consider starting an intraosseous (IO) line if IV access is
1. Maintain adequate airway, breathing, and circulation (the not possible and the seizure is prolonged or the patient is
“ABCs”). decompensating.
2. Terminate the seizure and prevent recurrence. During the administration of medications, continuous car-
3. Manage refractory status epilepticus (RSE). dio-respiratory monitoring is advised. Anticonvulsant medica-
4. Diagnose and initiate therapy for life-threatening causes of tions can cause loss of airway reflexes, respiratory depression,
CSE (e.g., hypoglycemia, meningitis, and cerebral space- hypotension, and cardiac arrhythmias.
occupying lesions). Increased intracranial pressure (ICP) or sepsis should be
considered and treated, as needed.
Maintain adequate ABCs Monitor the child’s temperature and aim for normothermia,
Inadequate airway maintenance is the most critical immediate using antipyretics as appropriate.
risk to the child or youth with CSE. Hypoxia is frequently Management of status epilepticus is outlined in Supplementary
present. Managing the airway includes positioning the child Figure 1. Medication doses are detailed in Table 2.
on their side and suctioning easily accessible secretions. The
mouth should not be pried open. After suctioning, reposition First-line treatment
the patient on their back and apply a chin lift or jaw thrust to Benzodiazepines are the first-line drugs of choice (6). Because
help open the airway, if needed. Administer 100% oxygen by rapid intervention is critically important, if no IV access is avai-
face mask, and use cardiorespiratory and oxygen saturation lable, benzodiazepines should be given by an alternate route
monitors. Consider assisted ventilation when the child shows while IV access is being obtained. First-line treatment may
signs of respiratory depression or oxygen saturations remain begin before arrival at the hospital (3,16,17).
low (under 90%) despite receiving 100% oxygen by face mask.
Increased heart rate and blood pressure (BP) are usually Prehospital
observed in the convulsing patient, but should return to nor- Treatment options include the following: intramuscular (IM),
mal when the seizure stops. Bradycardia, hypotension, and intranasal, or buccal midazolam; buccal lorazepam; or rectal
poor perfusion are ominous signs. They indicate severe hypoxia diazepam (Table 2). For prehospital treatment, midazolam is
Table 2. Anticonvulsant drug therapies for convulsive status epilepticus
52

Drug and Dose Maximum Rate Repeat Risks Comments

route
First-line treatments
Midazolam
• IV, IO 0.1 mg/kg 5 mg May repeat once after 5 minutes, Hypotension, respiratory
• IM 0.2 mg/kg 10 mg if still seizing. depression, sedation
• Buccal 0.5 mg/kg 10 mg
• Intranasal 0.2 mg/kg 10 mg (5 mg
per nostril)
Lorazepam
• IV, IO, 0.1 mg/kg 4 mg <2 mg/minute May repeat once after 5 minutes, Hypotension, respiratory Use sublingual tablets for
buccal (IV over 0.5–1 if still seizing. depression, sedation buccal route.
minute)
Diazepam
• IV, IO 0.3 mg/kg 5 mg (<5 years) Over 2 minutes May repeat once after 5 minutes, Hypotension, respiratory
10 mg (≥ if still seizing. depression, sedation
5 years)
• PR 0.5 mg/kg 20 mg
Second-line treatments
Fosphenytoin*
• IM, IV, IO 20 mg PE/kg 1,000 mg PE IV over 5 to Give an additional 5 mg PE/kg if Hypotension, bradycardia, Expensive. Do not use in
(phenytoin 10 minutes ineffective arrhythmia. combination with
equiva- (prepared in NS phenytoin. Not sug-
lents) or D5W) gested for use in seizures
due to intoxication.
Phenytoin*
• IV, IO 20 mg/kg 1,000 mg 1 mg/kg/ Give an additional 5 mg/kg if Hypotension, bradycardia, Do not use in combination
minute– over ineffective arrhythmia, IV extravasation with fosphenytoin. Not
20 minutes injury. suggested for use in
(prepared in NS seizures due to
only) intoxication.
Paediatrics & Child Health, 2021, Vol. 26, No. 1
Table 2. Continued

Drug and Dose Maximum Rate Repeat Risks Comments

route
Phenobarbital†
• IV, IO 20 mg/kg 1,000 mg 1 mg/kg/min – Respiratory depression May be best second-
over 20 minutes (especially if benzodi- line choice in infants
(prepared in NS azepine has been used), <6 months and in febrile
Paediatrics & Child Health, 2021, Vol. 26, No. 1

or D5W) hypotension, sedation status epilepticus, or if

(higher risk than on phenytoin
phenytoin) maintenance.
Levetiracetam
• IV, IO 60 mg/kg 3,000 mg Given over 5–15 Possible psychosis
minutes (pre- (low risk)
pared in NS or
D5W diluted to
15–50 mg/mL)
Additional second-line options, available in Canada only through Health Canada’s Special Access Programme
Drug and Dose Maximum Rate Repeat Risks Comments
route
Valproic acid
• IV, IO 30 mg/kg 3,000 mg Given over 5 min- Give an additional 10 mg/kg if Use with caution in pre-
utes (prepared ineffective existing liver or mito-
in NS or D5W) chondrial disease.

D5W 5% dextrose in water; IM Intramuscular; IO Intraosseous; IV Intravenous; NS Normal saline; PR Per rectum.
*If a patient is already receiving phenytoin, a partial loading dose of 5 mg/kg may be given. Subsequent doses may be given based on anticonvulsant levels.
†
If a patient is already on phenobarbital, a loading dose of 5 mg/kg may be given. Subsequent doses may be given based on anticonvulsant levels.
53
54 Paediatrics & Child Health, 2021, Vol. 26, No. 1

the preferred first-line medication for treatment of seizures in fosphenytoin, which is a water­soluble prodrug of phenytoin.
children without IV access (2,18–23). Therefore, fosphenytoin may be given by IM injection when
there is no IV or IO access. Fosphenytoin is the only second-
In hospital line medication that does not require IV access, but it is compa-
Either lorazepam (IV route) or midazolam (IV or IM route) ratively expensive and not universally available (6). Phenytoin
are equally appropriate first-line options, with similar efficacy and fosphenytoin should not be given to the same patient as
(18,24). When IV access is not rapidly available, alternative separate second-line drugs. If one has already been administe-
routes of administration (buccal, nasal, and IM) should be red, then the other should not be used.
considered. Lorazepam and midazolam have been shown to be The benefits of phenytoin include broad availability and less
more effective than diazepam or phenytoin for first-line treat- respiratory depression than phenobarbital.
ment of seizures (18,25,26). If the seizure has not stopped wit- Side effects of both phenytoin and fosphenytoin include
hin 5 minutes after a single dose of benzodiazepine, a second cardiac arrhythmias, bradycardia, and hypotension, such that
dose should be administered. If the seizure persists after continuous BP and electrocardiogram monitoring is recom-
two doses of benzodiazepine, including doses given before mended during infusion.
arrival at the hospital, initiating second-line medications is Phenytoin is not recommended as a second-line medication
recommended. Treatment with more than two doses of ben- to treat seizures caused by toxic ingestions or drug withdrawals,
zodiazepines is associated with increased risk for respiratory and may actually be harmful if used to treat seizures caused by
depression (17). ingestion of theophylline and tricyclic antidepressants (32,33).

Second-line treatment Phenobarbital

Current evidence suggests that fosphenytoin and phenytoin, Phenobarbital has similar anticonvulsant efficacy to phenytoin
levetiracetam, and valproate are equally effective for but has been associated with greater incidence of respiratory
managing seizures that are refractory to benzodiazepines depression, especially when used in conjunction with benzo-
(4,11,12,14,15,27–30). In Canada, fosphenytoin/phenytoin diazepines. Additional side effects include hypotension and
and phenobarbital have been the two most commonly used sedation. Phenobarbital’s mechanism of action is similar to the
second-line medications, due to familiarity and availability. benzodiazepines and thus it may be less effective for treating
Recently, IV levetiracetam has also become widely available for seizures refractory to these drugs (6).
use in managing CSE. As of July 2020, IV valproate is only avai- Phenobarbital may be the second-line agent of choice to treat
lable through the Health Canada’s Special Access Programme. children <6 months old, prolonged febrile seizures, and seizures
Variations in availability, potential for adverse reactions, and the caused by toxic ingestions or drug withdrawal (32,34,35). IV
individual clinical scenario will help guide the choice of second- phenobarbital is readily available in most hospitals. Alternative
line medications. medications should be considered when the patient is already
If one second-line medication is administered but is not experiencing respiratory depression or hemodynamic
successful in controlling the seizure, there is no clear consen- instability.
sus about further management (11). Options include the use
of another (different) second-line medication, or proceeding Levetiracetam
to the use of anesthetic agents. Within the first hour of seizure, The IV form of levetiracetam was brought to market in
there is little evidence to suggest that anesthetic agents are more Canada in 2019, and studies suggest that it has similar efficacy
efficacious than traditional second-line medications. Also, anes- to phenytoin, phenobarbital, and valproate (13,27,29,30,36–
thetic agents are more likely to cause respiratory depression 39). Levetiracetam appears to be a well-tolerated medication
and hypotension. Therefore, it is recommended that a second with fewer respiratory and cardiovascular side effects than
“second-line” medication be administered if the seizure persists phenytoin and phenobarbital. However, one study found
for 5 minutes after the initial second-line medication has been an increase in post-ictal psychosis when levetiracetam was
completely administered. used (13).
Levetiracetam should be considered as a second-line medi-
Phenytoin and fosphenytoin cation in children who are experiencing respiratory depression
Phenytoin has been shown to control 50% to 80% of pro- or are hemodynamically compromised. Levetiracetam has rela-
longed seizures (27,31). Because of its high pH, extravasa- tively fewer interactions with other medications compared with
tion of phenytoin can result in severe subcutaneous irritation other antiepileptic drugs, and may be a good choice in cases of
characterized by edema, discolouration, and pain distal to the polypharmacy (such as with chemotherapy or use of anti-in-
site of administration. This side effect does not occur with flammatory medications).
Paediatrics & Child Health, 2021, Vol. 26, No. 1 55

Valproate are already on anticonvulsant therapy. However, a full clinical

There is increasing interest in the use of IV valproate as a second- assessment should involve a search for precipitating causes,
line treatment. Recent trials have demonstrated similar efficacy with focus on signs of infection, meningeal irritation, trauma,
to phenytoin, levetiracetam, and phenobarbital, and valproate focal neurological deficits, and intoxication.
may cause less respiratory and cardiovascular compromise When the etiology of the seizure is unclear, consider the
(4,11,13,27,36,37,40–46). following investigations: blood for electrolytes, glucose (to
As of July 2020, access to IV valproate has been limited verify earlier bedside determination), complete blood count
because it is only available through Health Canada’s Special and differential, cultures (if sepsis is suspected), and blood
Access Programme. Valproate is a reasonable choice as a gas (1). Anticonvulsant levels should be measured for patients
second-line medication in children who are experiencing res- on long-term anticonvulsant therapy. Urine and blood can
piratory depression or are hemodynamically compromised. be sent for toxicology screening. Serum calcium, blood urea
Valproate is also useful in children who use this medication to nitrogen, magnesium, liver enzymes, lactate, and ammonia may
control their epilepsy but have had poor compliance. Valproate be required in specific cases. A decision regarding the need for
should be used with caution in children with pre-existing liver lumbar puncture (LP) should be deferred until the patient’s
disease. Valproate must be strictly avoided in children with vital signs are stable, there is no suspicion of increased ICP, and
known or suspected mitochondrial disease, including children the convulsion has stopped.
under 2 years old with unexplained developmental delay. When meningitis or encephalitis is believed to be causing sei-
zure, administer IV antibiotics and antivirals urgently. Attempts
Pyridoxine to obtain cultures should not delay treatment.
For children younger than 18 months of age in whom seizures A history of trauma, evidence of increased ICP, focal neuro-
may be caused by an undiagnosed metabolic disorder, a trial of logical signs, unexplained loss of consciousness, or suspicion of
pyridoxine (vitamin B6) 100 mg by IV initially, then 50 mg by cerebral herniation are indications for a computed tomography
IV or by mouth, twice a day, should be considered if there is a (CT) scan of the head. Head CT may be performed after the
failure to respond to the medications described above. ABCs have been stabilized and the convulsion has terminated
(1). A magnetic resonance image of the brain may be able to
identify problems not seen on CT, but this technology is not
Other medications
always readily available (16).
Paraldehyde has been used previously to manage CSE but is no
When there are clinical indications of raised ICP or hernia-
longer available in Canada. Lacosamide is another medication
tion, these must be treated immediately before further investiga-
that has shown some promise as a second-line agent, but there is
tion. A normal CT scan does not exclude significantly increased
insufficient data to recommend it routinely at this time (12,37).
ICP. LP must be deferred when clinical or radiological signs of
increased ICP are present.
Manage refractory status epilepticus
Intoxication should always be considered. When intoxication
CSE that is unresponsive to adequate doses of first- and second-
is proven or strongly suspected, and the convulsive activity has
line therapies is considered to be refractory, although some orga-
stopped, consider using activated charcoal as soon as the airway
nizations require that the seizure lasts longer than 1 hour to meet
has been protected.
criteria for RSE (4,16,47). Beyond the first hour of seizure, second-
line medications are less likely to be effective and new medication
strategies are used. RSE strategies may involve administering a Nonconvulsive status epilepticus
continuous midazolam infusion, pentobarbital, high-dose phe- Non-CSE refers to a persistent change in the baseline level of
nobarbital, or propofol. These medications have significant risks, consciousness, with associated continuous epileptiform changes
including respiratory suppression and hypotension. At this stage, in the electroencephalogram (EEG), but without motor signs.
the patient’s care is beyond the scope of the usual ED setting, If the child’s level of consciousness does not recover as expected
and transfer to a paediatric intensive care unit with neurological after the convulsion has stopped, or when neuromuscular paralysis
consultation for further management is necessary. is being used, then an EEG should be performed to exclude non-
CSE. When an EEG cannot be obtained, consultation with neuro-
Diagnose and initiate therapy for life-threatening logy and empirical treatment for non-CSE is indicated (9).
causes of CSE
Investigations should be individualized based on clinical scena-
rio (Table 1). The most common cause of CSE is a prolonged CONCLUSION
febrile seizure, which may not require an extensive workup. The Status epilepticus is a common paediatric neurological
same may apply to children with a known seizure disorder who emergency. Appropriate management includes maintaining
56 Paediatrics & Child Health, 2021, Vol. 26, No. 1

respiratory and hemodynamic stability, prompt administration 9. National Institute for Health and Care Excellence (NICE). Treating Prolonged
or Repeated Seizures and Status Epilepticus, June 11, 2020. pathways.nice.org.uk/
of appropriate medications at appropriate doses, and the spe- pathways/epilepsy (Accessed August 5, 2020).
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Epilepticus Algorithm, March 2020. https://trekk.ca/system/assets/assets/
causes of seizure. All health care professionals involved in the attachments/453/original/2020-03-09_SE_algorithm_v_3.0.PDF?1583872609
acute medical management of children must be ready to apply (Accessed August 5, 2020).
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SUPPLEMENTARY DATA vulsive status epilepticus (SE): A prospective randomised controlled study of com-
bined treatment with intravenous lorazepam with either phenytoin, sodium valproate
An algorithm on managing status epilepticus is available as a or levetiracetam–Pilot study. Epilepsy Res 2015;114:52–8.
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online. status epilepticus. Neurocrit Care 2012;17(1):3–23.
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Treatment guidelines and protocols. Emerg Med Clin North Am 2011;29(1):51–64.
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CANADIAN PAEDIATRIC SOCIETY ACUTE CARE COMMITTEE

Members: Kevin Chan MD (Chair), Kimberly Dow MD (Board Representative), Karen Gripp MD, Kristine Krmptoic MD, Kyle C
McKenzie MD (past member),
Liaisons: Laurel Chauvin-Kimoff MD, CPS Paediatric Emergency Medicine Section; Sidd Thakore MD, CPS Hospital Paediatrics Section
Principal authors: Kyle C. McKenzie MD, Cecil D. Hahn MD, Jeremy N. Friedman MD