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
- Neurology Consult
- Further diagnostic testing
- ASM levels
- cEEG duration
- ASM Discontinuation
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
20 mg/kg IV
Reassess in 30 min
Reassess in 30 min
Administer 2nd Line Fosphenytoin
20 mg PE/kg IV
20 mg PE/kg IV
Reassess in 30 min
Repeat 2nd Line Fosphenytoin
10-20 mg PE/kg IV
10-20 mg PE/kg IV
Reassess in 30 min
Administer 3rd Line Levetiracetam
60 mg/kg IV
60 mg/kg IV
Reassess in 15 min
- 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
Consider when seizure free for 2-3 days
Posted: October 2024
Editors: Clinical Pathways Team
Editors: Clinical Pathways Team
Evidence
- Neonatal Seizures: Case Definition and Guidelines for Data Collection, Analysis, and Presentation of Immunization Safety Data
- Treatment of Seizures in the Neonate: Guidelines and Consensus-Based Recommendations—Special Report from the ILAE Task Force on Neonatal Seizures
- Treatment of Neonatal Seizures: Comparison of Treatment Pathways From 11 Neonatal Intensive Care Units
- Safety of Early Discontinuation of Antiseizure Medication After Acute Symptomatic Neonatal Seizures
- The ILAE Classification of Seizures and the Epilepsies: Modification for Seizures in the Neonate
- Management of Seizures in Neonates with Neonatal Encephalopathy Treated with Hypothermia
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