N/IICU Clinical Pathway for the Treatment and Monitoring
for Neonatal Seizure/Status Epilepticus

  • Most seizures in neonates are acute, provoked seizures related to HIE, ICH, ischemic stroke or infection.
  • Neonatal epilepsy due to cortical malformation, genetic conditions or inborn errors of metabolism are rare.
 
 
  • Consider Benzodiazepine if concern for seizure but Highly Probable Criteria not met
    • e.g., other movements or paroxysmal events
  • Transfer to Center with cEEG
    • Higher-level diagnostic work-up needed
    • More than 1-2 ASM needed
  • Anti-Seizure Medications (ASM)
  • Progress rapidly through ASM to stop seizures
  • Prepare next ASM while monitoring response
  • ASM
    • Route
    • Loading and max dose
    • Concentration, infusion rate
  • Other Conditions
    • Genetic epilepsy (including family history of channelopathy), metabolic therapies, cardiac disease
 
 
Highly Probable Seizure
  • Continuous EEG (cEEG) seizure (gold standard)
  • Amplitude integrated EEG (aEEG) seizure
  • Focal clonic seizure or focal tonic-clonic seizure
 
 
  • Neurology consult
  • Begin cEEG
Administer 1st Line Phenobarbital
20 mg/kg IV
 
 
Reassess in 30 min
Repeat 1st Line Phenobarbital
10-20 mg/kg IV
Up to cumulative dose of 40 mg/kg
 
 
Reassess in 30 min
Administer 2nd Line Fosphenytoin
20 mg PE/kg IV
 
 
Reassess in 30 min
Repeat 2nd Line Fosphenytoin
10-20 mg PE/kg IV
 
 
Reassess in 30 min
Administer 3rd Line Levetiracetam
60 mg/kg IV
 
 
Reassess in 15 min
Refractory Seizures
Administer 4th Line Midazolam
Bolus + Infusion
  • Reconsider
    • Etiology
    • Therapies for genetic/metabolic conditions
    • In-person Neurology consult
 
 
Discontinuing ASM in Acute Symptomatic Seizure
Consider when seizure free for 2-3 days