EEG Monitoring Clinical Pathway — PICU, N/IICU, and CICU

Benzodiazepines and Anti-Seizure Medications

Consider the following medications for the Seizure Action Plan.

See Status Epilepticus Clinical Pathway for guidance on management.

Medication	Management Role	Dose (mg/kg)	Max Dose (mg)	Considerations
Lorazepam	Initial treatment	0.1 mg/kg IV	4 mg	May repeat dose in 5 mins if seizure persists Consider other options if recently received benzodiazepines or a benzodiazepine drip
Anti-Seizure Medications
Levetiracetam	1^st Line: Non-neonates	60 mg/kg IV	4,500 mg	ED, ICUs, 9S Local Pyxis Administration Infuse IV over 10 mins
Phenobarbital	1^st Line: Neonates	20 mg/kg IV Followed by an additional IV 10-20 mg/kg if indicated	Single Dose Max 2,000 mg	ED, ICUs, 9S Doses ≤ 500 mg Local Pyxis, dilute to 10 mg/mL Doses > 500 mg Pharmacy, no additional dilution required Administration Maximum concentration: 10 mg/mL Maximum infusion rate: Infants/children: 1 mg/kg/min up to 30 mg/min Adults: 60 mg/min Consider alternatives if there are concerns for: Hypotension or respiratory depression Additional Dose 10-20 mg/kg/dose Guidance for Treatment of Neonatal Seizures
Fosphenytoin	Alternative: Neonates and non-neonates	IV/IM 20 mg PE/kg Followed by an additional IV 10 mg PE/kg if indicated PE = phenytoin equivalents	Single Dose Max 1,500 mg PE If an additional dose is given: Max 1,500 mg PE	ED Dose ≤ 1,000 mg PE Local Pyxis med refrigerator Dose > 1,000 mg PE Main ED Team: Preparation by ED Pharmacist Resuscitation Room: Preparation by ED Pharmacist or Resuscitation Med RN Call ED Pharmacist to bring vials to the Resuscitation Bay Utilize 2 syringe method to prepare doses > 1,000 mg PE Syringe 1 dilute to 25 mg PE/mL up to 1,000 mg PE Syringe 2 dilute to 25 mg PE/mL up to 500 mg PE Administer syringe 1 + 2 to complete dose up to 1,500 mg PE PICU, N/IICU, 9S Dose ≤ 1,000 mg PE Local Pyxis, dilute to 25 mg PE/mL Dose > 1,000 mg PE Pharmacy, no additional dilution required Other Locations Including CICU Pharmacy Administration Maximum IV concentration: 25 mg PE/mL Maximum IV infusion rate: Infants/children: 2 mg PE/kg/min Adults: 150 mg PE/kg/min Maximum IM concentration: 50 mg PE/mL Consider alternatives if: concern for cardiac dysfunction Additional Dose 10 mg PE/kg/dose IV or IM
Valproate Sodium	Alternative: non-neonates 1^st Line: Generalized epilepsy	IV 40 mg/kg Followed by an additional IV 20 mg/kg if indicated	Single Dose Max 3,000 mg	All doses from pharmacy Administration Maximum IV infusion rate: 5 mg/kg/min Consider alternatives for: Age < 2 yrs, hepatic dysfunction, pancreatitis, thrombocytopenia or metabolic disease Use first line for: Known generalized epilepsy diagnoses including childhood absence epilepsy, juvenile absence epilepsy, and juvenile myoclonic epilepsy Additional Dose 20 mg/kg/dose

Anti-Seizure Medication: Other Considerations

Condition	Recommendations
Hepatic dysfunction	Consider levetiracetam Avoid valproate
Cardiac dysfunction	Consider levetiracetam Avoid fosphenytoin
Respiratory depression Hypotension	Consider levetiracetam or valproate Avoid phenobarbital
Hypoalbuminemia Polypharmacy with hepatic metabolized medications	Consider levetiracetam Consider calculating adjusted phenytoin levels When available, consider sending drug levels
Thrombocytopenia Metabolic disease Encephalopathy of unknown etiology < 2 yrs of age Pancreatitis	Avoid valproate
No IV access	Consider Fosphenytoin IM 20 mg PE/kg, max dose: 1,500 mg PE Diazepam PR 0.5 mg/kg, max dose: 20 mg Midazolam buccal/intranasal 0.3 mg/kg, 5 mg/ml concentration, max dose: 10 mg Atomizer and dead space adjustment needed for intranasal administration

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