Key points
- Treat a seizure lasting 5 minutes or more as status epilepticus: ABCs, glucose, IV/IO access, then a benzodiazepine.
- Lorazepam 0.1 mg/kg IV (max 4 mg); repeat once after 5 minutes if still seizing.
- Still seizing after 2 benzodiazepine doses: levetiracetam 60 mg/kg, fosphenytoin 20 mg PE/kg or valproate 40 mg/kg IV.
- Hypoglycemia: D10W 5 mL/kg IV gives 0.5 g/kg of glucose.
- Simple febrile seizure: age 6–60 months, generalized, under 15 minutes, once in 24 hours.
- After a simple febrile seizure, no routine EEG, imaging or blood tests; about 1 in 3 children have another.
- First afebrile seizure: EEG is recommended; labs and imaging only when the history or exam points to them.
Status epilepticus: first 5 minutes
Start the clock at seizure onset. Stabilize while the first drug is drawn up: the 2 run in parallel.
- Airway, breathing and circulation: position, suction, oxygen, assist ventilation if needed.
- Monitor heart rate, oxygen saturation and blood pressure.
- Check a bedside glucose. If low, give dextrose 0.5 g/kg IV (D10W 5 mL/kg).
- Obtain IV or IO access; send electrolytes, calcium, magnesium and drug levels as indicated.
- Treat at 5 minutes: do not wait for IV access to give the first benzodiazepine.
First-line: benzodiazepines
Give no more than 2 benzodiazepine doses in total, counting doses given at home or by EMS. More doses add respiratory depression without much added benefit.
| Route | Drug and dose |
|---|---|
| IV | Lorazepam 0.1 mg/kg (max 4 mg), may repeat once |
| IV | Diazepam 0.15–0.2 mg/kg (max 10 mg), may repeat once |
| IM | Midazolam 5 mg for 13–40 kg, 10 mg for over 40 kg, single dose |
| Intranasal or buccal | Midazolam, about 0.2 mg/kg (max 10 mg) |
| Rectal | Diazepam 0.2–0.5 mg/kg (max 20 mg) |
Second-line drugs and refractory status
If seizures continue after 2 benzodiazepine doses (about 20 minutes), give one IV loading drug. In the ESETT trial the 3 options below stopped seizures equally often, in about half of patients.
- Levetiracetam 60 mg/kg IV (max 4,500 mg), over about 10 minutes.
- Fosphenytoin 20 mg PE/kg IV (max 1,500 mg PE); infuse no faster than 2 mg PE/kg/min or 150 mg PE/min, whichever is slower. Watch for hypotension and arrhythmia.
- Valproate 40 mg/kg IV (max 3,000 mg). Avoid in POLG mitochondrial disease, liver disease and suspected metabolic disease; use caution under age 2.
- Phenobarbital 15–20 mg/kg IV if the others are not available.
- Still seizing (refractory status): intubation, continuous infusion (midazolam, pentobarbital, propofol) and EEG monitoring in intensive care. Ketamine is not contraindicated and is an option for refractory status.
- Infant with refractory seizures: consider pyridoxine-dependent epilepsy and give IV pyridoxine; in any child, consider isoniazid toxicity.
Febrile seizures: definition and evaluation
A febrile seizure occurs in a child 6–60 months old with a temperature of 100.4°F (38.0°C) or higher, without CNS infection, metabolic cause or prior afebrile seizure.
- Main task after a simple febrile seizure: find the source of the fever and look for meningitis.
- Lumbar puncture when there are meningeal signs or other signs of CNS infection, and only when it is safe.
- LP is an option at 6–12 months if Hib or pneumococcal vaccines are missing or unknown, and in a child pretreated with antibiotics.
- A well child back to baseline with a normal exam needs no routine EEG, neuroimaging or blood tests.
- Complex febrile seizure: no automatic CT and LP; choose tests from the exam, recovery and likely cause.
- Infant under 6 months with fever and seizure: outside the febrile-seizure age range, so assess urgently for infection and metabolic causes; imaging depends on the findings.
| Simple | Complex (any one) |
|---|---|
| Generalized | Focal features |
| Under 15 minutes | 15 minutes or longer |
| Once in 24 hours | Recurs within 24 hours |
Febrile seizures: counseling
- About 1 in 3 children have another febrile seizure; risk is higher when the first happens before 12 months.
- Epilepsy risk after a simple febrile seizure is low, about 1%, only slightly above the general population.
- Antipyretics make the child comfortable but do not prevent recurrence.
- Daily or intermittent antiseizure drugs are not recommended for simple febrile seizures.
- Do not discharge a child who has not returned to baseline, has a focal deficit, may have a serious infection or keeps seizing.
First afebrile seizure and breakthrough seizures
- A child who has fully recovered with a normal exam does not need admission or a broad lab panel: test by history and exam.
- Labs (glucose, sodium, calcium) when there is vomiting, diarrhea, dehydration, failure to return to baseline, or age under 6 months.
- Young infant: ask about extra free water or wrongly diluted formula (hyponatremia).
- Toxicology testing when the history, access to medicines or the exam suggests an exposure.
- Urgent imaging for a new focal deficit (for example one-sided weakness) or failure to return to baseline; otherwise MRI is non-urgent when indicated.
- EEG is recommended after a first unprovoked seizure; arrange prompt neurology follow-up.
- Recurrent seizure-like events need neurology evaluation even when the exam is normal.
- Known epilepsy with a breakthrough seizure: check missed doses, weight gain without a dose change, intercurrent illness and sleep loss.
Discharge, first aid and rescue plans
- Discharge when the child is at neurologic baseline, well appearing, drinking, the cause is addressed and follow-up is reliable.
- Consider a home rescue medicine (intranasal midazolam or diazepam, or rectal diazepam) with a written seizure action plan, especially after prolonged or clustered seizures.
- Caregiver first aid: time the seizure, protect the head, turn onto the side, loosen tight clothing; never restrain or put anything in the mouth.
- Call 911 if a seizure lasts 5 minutes, seizures repeat without recovery, breathing is difficult, there is injury, it happens in water, or it is the first seizure.
Common questions
When is a seizure status epilepticus?
For treatment, any convulsive seizure lasting 5 minutes or more, or repeated seizures without return to baseline between them.
Does a simple febrile seizure need an EEG or CT?
No. A well child back to baseline with a normal exam needs no routine EEG, imaging or blood tests. Focus on the cause of the fever.
Which second-line drug is best for status epilepticus?
Levetiracetam, fosphenytoin and valproate worked equally well in the ESETT trial. Choice depends on the patient: avoid valproate in POLG or liver disease.
Study this topic
Sources
- American Epilepsy Society 2016: Treatment of convulsive status epilepticus in children and adults (Epilepsy Curr)
- ESETT: Randomized trial of three anticonvulsants for status epilepticus (NEJM 2019)
- AAP 2011: Neurodiagnostic evaluation of the child with a simple febrile seizure (Pediatrics)
- AAP 2008: Long-term management of the child with simple febrile seizures (Pediatrics)
- AAN/CNS/AES: Evaluating a first nonfebrile seizure in children (Neurology 2000)
Written for Pedemy in our own words from the sources above; checked November 2026. For education only, not medical advice; check doses and local protocols before treating a patient. Pedemy is independent and not affiliated with or endorsed by the organizations cited.