Timeline* | Assessment | Supportive care | Seizure therapy |
0 to 5 minutes | Obtain initial vital signs, including temperature | Open airway Suction secretions Administer 100% O2 | Benzodiazepine: Lorazepam 0.1 mg/kg IV or IO, maximum 4 mg OR Diazepam 0.2 mg/kg IV or IO, maximum 10 mg IV or IO access not achieved within 3 minutes: Buccal midazolam 0.3 to 0.5 mg/kg, maximum 10 mg OR IM midazolam 0.1 to 0.2 mg/kg, maximum 10 mg OR Rectal diazepam (Diastat gel or injection solution given rectally) 0.5 mg/kg, maximum 20 mg |
Identify airway obstruction and hypoxemia | Place continuous cardiorespiratory monitors and pulse oximetry | ||
Identify impaired oxygenation or ventilation | Perform bag-valve-mask ventilation, as needed Prepare for RSI* | ||
Obtain rapid bedside blood glucose and other studies, as indicated¶ | Establish IV or IO access | ||
Evaluate for signs of sepsis/meningitis | Treat hypoglycemia (IV dextrose 0.25 to 0.5 g/kg) | ||
Evaluate for signs of head trauma | Treat fever (acetaminophen 15 mg/kg rectally) | ||
5 to 10 minutes | Reevaluate vital signs, airway, breathing, and circulation | Maintain monitoring, ventilatory support, and vascular access | Benzodiazepine: second dose |
Evaluate for signs of trauma, sepsis, meningitis, or encephalitis | Give antibiotics if signs of sepsis or meningitisΔ | ||
10 to 15 minutes | Reevaluate vital signs, airway, breathing, and circulation | Maintain monitoring, ventilatory support, and vascular access | Levetiracetam 60 mg/kg IV or IO, maximum single dose 4500 mg OR Fosphenytoin 20 mg PE per kg IV or IO, maximum single dose 1500 mg◊ OR Valproate 20 to 40 mg/kg IV or IO OR Phenobarbital 20 mg/kg IV or IO, maximum 1 g (expect a respiratory depression with apnea)¥ |
Place second IV | |||
RSI potentially indicated* | |||
15 to 30 minutes | Reevaluate vital signs, airway, breathing, and circulation | Maintain monitoring, ventilatory support, and vascular access | Fosphenytoin (if not already given) 20 mg PE per kg IV or IO◊ OR Valproate (if not already given) 20 to 40 mg/kg IV or IO OR Phenobarbital (if not already given) 20 mg/kg IV or IO, maximum 1 g (10 mg/kg if phenobarbital already given)¥ OR Levetiracetam (if not already given) 60 mg/kg IV or IO AND Pyridoxine 100 mg IV or IO in infants <1 year of age Pyridoxine 70 mg/kg IV or IO, maximum 5 g, if INH poisoning suspected Obtain pediatric neurology consultation‡ |
Obtain continuous EEG monitoring, if available |