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Child Health Guideline Identifier

Convulsions - Status Epilepticus

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For the treatment of neonatal seizures see Newborn Services Clinical Guidelines

Management algorithm

Management algorithm 2019

Definition of Status Epilepticus

Recurrent seizures without complete recovery of consciousness between attacks, or continuous seizure activity for more than 30 minutes. This may occur with or without impairment of consciousness.

Includes generalized convulsive seizures, nonconvulsive seizures (absence status, complex partial status) and continuous focal motor seizure activity.

Nonconvulsive or partial motor status is not associated with the same severity of sequelae or urgency of treatment as generalized convulsive status, but if sustained may still result in permanent damage. Further consultation with the neurology consultant on call should be obtained for these patients before progressing down the treatment algorithm

Most seizures in childhood stop within 5 minutes. Supportive care is the mainstay of treatment in this time period.

Treatment should start if the seizure has not spontaneously terminated after 5 minutes. Seizures of longer duration are more difficult to terminate and may be associated with neurological sequelae. 

Assessment and management

Concurrent assessment and management should occur if seizure activity is continuing.

Key features include:

Airway  Airway compromise
- Secretions and trismus are common
- Complete airway obstruction is very rare

Airway positioning - eg jaw thrust 

Avoid blind suctioning 
Breathing Peri-oral cyanosis common    

Apply oxygen 
Circulation Tachycardia and poor peripheral perfusion common    

Shock uncommon (if present consider sepsis as underlying cause) 

Ensure appropriate monitoring, including BP    

Check blood glucose 
Give IV glucose if low (2mLs/kg 10% glucose) 

Is the patient still convulsing?
Critical concept is that longer seizures = less motor movements
- Limb Tone
- Pupils - if unreactive then ongoing seizure likely
- Eyes - if deviation of both eyes then ongoing seizure likely, however absence of eye deviation does not
  exclude ongoing seizure activity  
- Response to pain - bilateral localisation to pain 

Differential diagnosis - can be difficult: 
-  Posturing
   Raised ICP
   Cerebral Palsy

-  Dystonic reactions
   Eg post metoclopramide

-  Pseudo-seizures
   Bilateral motor movements without loss of consciousness
   Lack of post ictal period

Consider cause of seizures as some causes may require specific emergency management :

-  Toxicology
   Wide range of pharmaceuticals (eg tricyclic antidepressants) 
    Recreational drugs (unintentional or intentional)

-  Metabolic
    Electrolyte disturbance (eg Diabetes insipidus)

-  Infective

-  Epilepsy

-  Trauma (including non-accidental injury)

-  Intra-cranial
   Blocked VP shunt  
   CVA/Intracranial bleed   

- Hypertensive 

Seek additional information 
-  Onset seizure activity
-  Focal onset
-  Pre Hospital treatment and any chronic treatment
-  Previous successful hospital treatment

APLS Medication List - Drugs in Status Epilepticus

from APLS 5th Edition Course manual

 Drug  Route  Dose  Comments
Midazolam  IV/IO 
0.15 mg/kg
0.2 mg/kg
0.5 mg/kg
0.5 mg/kg 
Max 10mg.
Takes effect within minutes but shorter duration of effect than lorazepam. Can depress respiration, particularly if repeated dosing. Is usually short-lived and is usually easily managed with bag-mask-valve ventilatory support. IM midazolam more effective than buccal or intra-nasal routes. Intra-nasal route requires mucosal atomiser device for optimal delivery. Buccal midazolam is twice as effective as rectal diazepam, but both drugs produce the same level and degree of respiratory depression. 
Diazepam  IV/IO
0.25 mg/kg
0.5 mg/kg
Max 10mg.
Rapid onset, duration less than 1 hour. Well absorbed rectally. Widely used but may now be superseded by the more effective midazolam or lorazepam where available. 
Lorazepam  IV/IO  0.1 mg/kg Max 4 mg.
Dilute with saline or water to at least twice the 'neat' volume and give over 2 minutes.
Consider using 0.05mg/kg if prior benzodiazepines or likely to have impaired respiratory drive.

Equally or more effective than midazolam and diazepam, possibly less respiratory depression. Longer duration of action (12-24 hours) 
Phenytoin  IV/IO  20 mg/kg  Max 1g.
Give over 20 minutes, made up in 0.9% sodium chloride solution to a maximum concentration of 10mg in 1 ml. Can cause dysrhythmias and hypotension, therefore monitor ECG and BP. Little depressant effect on respiration. 
Phenobarbitone  IV/IO  20 mg/kg  Max 1g.
Give over 20 minutes. Ensure airway support available, often causes respiratory depression. Monitor blood pressure. 
Paraldehyde  PR  0.4 ml/kg  Max 10 ml.
Make up as 50:50 solution in olive oil or 0.9% sodium chloride (avoid Arachis oil because children with peanut allergy may react to it). Can cause rectal irritation. Avoid IM use as causes severe pain and may lead to sterile abscess formation. Paraldehyde causes little respiratory depression. Avoid in liver disease. Takes 10-15 minutes to act, sustained for 2-4 hours. Don't leave paraldehyde standing in a plastic syringe for longer than a few minutes. 

Drug Summaries


Paraldehyde is formulated for Intramuscular use. However due to the risks of severe muscle necrosis, the most common method of use is to administer rectally. For rectal administration, the intramuscular preparation has to be diluted with oil.

Rectal paraldehyde

  • May be effective in terminating status when IV access is not available.
  • Dose: 0.4ml/kg, q 2-4 hours as required
  • Method: Dilute 1:2 in olive oil
  • Action may be delayed up to 2-4 hours.
  • Metabolic acidosis is a possible complication in infants.

Notes on Paraldehyde

  • Can be administered from plastic syringes if used quickly.
  • Recommended administration in 20ml syringe attached to 10F feeding tube, inserted 10cm rectally. Hold buttock cheeks together for 2-3min (PR paraldehyde is a powerful GI stimulant). Insoluble at room temperature in solutions above 7.8% (1 in 12). Warm ampoules if crystals appear. Do not take from a vial that is discoloured or has been open for a while. Paraldehyde degrades to acetate and acetaldehyde on contact with air, and these may be fatal.

Valproate therapy

Valproate can be given intravenously in convulsive status epilepticus.

  • Dose = 40 mg/kg IV sodium valproate given over 10 minutes (diluted to a maximum concentration of 50mg/ml with 0.9% sodium chloride or 5% glucose)

Peak levels are reached within 30 minutes, with an effective half-life of approximately 12 hours. A continuous intravenous infusion can also be considered if the initial dose was effective. There are also reports of the effective use of intravenous valproate in nonconvulsive status.

Levetiracetam therapy

  • Dose = 40mg/kg IV levetiracetam (maximum 3g) given over 5 minutes. Dilute 1:1 to give concentration of 50mg/1ml with sodium chloride 0.9% or 5% glucose to a minimum of 10ml.

Information for Families

The New Zealand Paediatric Neurology Clinical Network have produced some information sheets for families on epilepsy, seizures and medication.

Did you find this information helpful?

Document Control

  • Date last published: 06 April 2017
  • Document type: Clinical Guideline
  • Services responsible: Children’s Emergency Department, Paediatric Intensive Care Unit, Paediatric Neurology
  • Intended users: Emergency Department, Intensive Care and Clinical Wards
  • Author(s): Claire Spooner, Heidi Baker, Mike Shepherd, John Beca
  • Editor: Greg Williams
  • Review frequency: 2 years

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