0-5 minutes: stabilization
Time the seizure from its true onset and count any benzodiazepine already given before arrival. Assess airway, breathing, circulation and neurologic status; monitor vital signs and ECG; give oxygen by nasal cannula or mask and consider intubation if breathing needs support. Get IV access and send electrolytes, a blood count, and a toxicology screen and drug levels if appropriate.
Check a finger-stick glucose. If it is under 60 mg/dL, give 2 mL/kg D25W IV at 2 years and over, or 4 mL/kg D12.5W IV under 2 years; both equal 0.5 g/kg.
5-20 minutes: a benzodiazepine
IM midazolam, IV lorazepam and IV diazepam are equivalent first-line options. Choose one and give an adequate single full dose. Only lorazepam and diazepam may be repeated once. Draw up the second-line drug while the benzodiazepine goes in.
If none of the three is available, the options are rectal diazepam, intranasal or buccal midazolam, or IV phenobarbital.
20-40 minutes: second therapy
There is no evidence-based first choice. Give one of levetiracetam, fosphenytoin or valproic acid as a single dose, chosen by contraindications and availability. The ESETT trial found the three about equally effective, stopping seizures in roughly half of patients. Phenobarbital is the option if none of these is available and it has not already been given. Reassess the airway in this phase.
Avoid valproate in suspected mitochondrial or metabolic disease, liver disease, and under 2 years when possible. Monitor ECG and blood pressure during a fosphenytoin infusion.
Dose table
Doses are per kg and capped at each source's maximum. The last column shows the dose for a 20 kg child, the calculator's default weight.
| Drug | Phase | Dose | Maximum | 20 kg example |
|---|---|---|---|---|
| Midazolam IM | 5-20 min | 5 mg for 13-40 kg, 10 mg over 40 kg (AES bands) | 10 mg | 5 mg |
| Lorazepam IV | 5-20 min | 0.1 mg/kg, may repeat once | 4 mg | 2 mg |
| Diazepam IV | 5-20 min | 0.15-0.2 mg/kg, may repeat once | 10 mg | 3-4 mg |
| Diazepam rectal | If none of the above | 0.2-0.5 mg/kg by age (0.5 at 2-5 y, 0.3 at 6-11 y, 0.2 at 12 y and over) | 20 mg | Depends on age |
| Phenobarbital IV | If none of the above | 15 mg/kg, single dose | None listed | 300 mg |
| Levetiracetam IV | 20-40 min | 60 mg/kg, single dose | 4,500 mg | 1,200 mg |
| Fosphenytoin IV | 20-40 min | 20 mg PE/kg, single dose | 1,500 mg PE | 400 mg PE |
| Valproic acid IV | 20-40 min | 40 mg/kg, single dose | 3,000 mg | 800 mg |
| Midazolam load / infusion | 40-60 min | 0.2 mg/kg, then 0.05-2 mg/kg/hr | None listed | 4 mg, then 1-40 mg/hr |
| Pentobarbital load / infusion | 40-60 min | 5-15 mg/kg, then 0.5-5 mg/kg/hr | None listed | 100-300 mg, then 10-100 mg/hr |
| Propofol load | 40-60 min | 1-2 mg/kg | None listed | 20-40 mg |
- Under 13 kg, the AES algorithm gives no IM midazolam band; 0.2 mg/kg (maximum 10 mg) is common practice
- Intranasal (0.2 mg/kg) and buccal (0.3 mg/kg) midazolam, each maximum 10 mg, are common practice; the AES lists these routes without a dose
- Rectal diazepam under 2 years is outside the label
40-60 minutes: third therapy
There is no clear evidence to guide this phase. Options are a repeat second-line drug (a different agent) or anesthetic doses of midazolam, pentobarbital, propofol or thiopental, all with continuous EEG. Airway control is likely needed. Prolonged high-dose propofol in children risks propofol infusion syndrome.
Call neurology and intensive care and start continuous EEG. Look again for a cause: glucose, sodium, calcium, toxins including isoniazid, CNS infection and head injury. In infants with refractory seizures, consider pyridoxine 100 mg IV.
Neonates
Seizures in the first month follow neonatal seizure guidance, where phenobarbital is the usual first-line drug.
Use the free tool
Status epilepticus clock with weight-based doses, plus febrile and first-seizure decision branches.
Open Seizures →Common questions
What is the lorazepam dose for status epilepticus in children?
0.1 mg/kg IV, maximum 4 mg. It may be repeated once.
What IM midazolam dose does the AES algorithm use?
5 mg for children 13 to 40 kg and 10 mg over 40 kg, as a single dose. Under 13 kg there is no AES band; 0.2 mg/kg, maximum 10 mg, is common practice.
Which second-line drug should be used?
None is preferred. Levetiracetam 60 mg/kg (max 4,500 mg), fosphenytoin 20 mg PE/kg (max 1,500 mg PE) and valproic acid 40 mg/kg (max 3,000 mg) were about equally effective in ESETT.
How many benzodiazepine doses should be given?
One adequate full dose. Only lorazepam and diazepam may be repeated once. Count any dose given before arrival.
Sources
Glauser T et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults. American Epilepsy Society. Epilepsy Currents 2016;16(1):48-61, and its treatment algorithm.; Kapur J et al. Randomized trial of three anticonvulsant medications for status epilepticus (ESETT). N Engl J Med 2019;381:2103-2113.; Brophy GM et al. Guidelines for the evaluation and management of status epilepticus. Neurocritical Care Society. Neurocrit Care 2012;17(1):3-23 (anesthetic infusion ranges).; US FDA prescribing information for diazepam rectal gel (age-based rectal dosing).
For education only, not medical advice. Always confirm against current guidelines and your local protocols. Pedemy is independent and not affiliated with or endorsed by the organizations cited.