1. Assess and treat ABC's
    1. Consider use of nasopharyngeal airway or oropharyngeal airway.
    1. Assist respirations with bag-valve-mask as needed.
    2. Consider endotracheal intubation if apneic or unable to protect airway (see Intubation/RSI)
    3. Consider IO placement if unable to successfully place peripheral IV
  2. Consider and treat underlying cause of seizure activity
    1. Events preceding and description of the seizure
    2. Electrolyte and glucose levels
    3. Traumatic events (consider c-spine immobilization)
    4. Exposure to toxins
    5. Neurological problems
    6. Recent febrile illness
    7. Meningitis
    8. Anoxia
  3. Obtain labs as appropriate. Consider glucose, electrolytes, ABG and blood cultures
  4. Avoid continued use of neuromuscular blocking agents as they are not anticonvulsants and will mask clinical seizures.
  5. Protect from external stimuli such as excessive noise, strobe effect, etc.
  6. Anticonvulsants:
    1. Lorazepam (Ativan): I.V. 0.1 mg/kg (max single dose= 4 mg) IV push over 2-5 minutes. May repeat in 10-15 minutes to a max total dose of 8 mg in 12 hr
    2. Consider loading with longer acting anticonvulsant
      1. Fosphenytoin (Cerebyx)
        1. The dose, concentration in solutions, and infusion rates for Fosphenytoin are expressed as Phenytoin Sodium equivalents (PE).
        2. Consider loading dose: IV 15-20mg PE/kg I.V. administered at 100-150mg PE/min. Do not administer at a rate faster than 150 PE mg/ml.
      2. Phenobarbital
        1. 15-20 mg/kg; may repeat dose after 20 minutes (maximum total dose 40mg/kg).
      3. Keppra (Levetiracetam): 60 mg/kg IV loading dose (up to 4500 mg)

Special Considerations:

  • Hypocalcemia
  • Hypoglycemia


  1. New guideline for treatment of prolonged seizures in children and adults- 02/2016.