Pathway Background and Objectives

Status epilepticus is a relatively common medical presentation, with 18-41 per 100,000 children presenting to emergency rooms each year. The American Epilepsy Society made recommendations in 2016 for treatment of prolonged seizures, which includes level A evidence of administration of benzodiazepines for seizure cessation in the first 20 minutes of seizure activity. Benzodiazepines are y-aminobutyric acid (GABA) receptor agonists, designed to increase inhibitory CNS activity to subsequently diminish seizure activity. The importance of early benzodiazepine administration is predicated on the idea that GABA receptors are rapidly phosphorylated and dephosphorylated during seizures which internalizes those receptors, making them unavailable for use as the seizure progresses. There is little specific data on outcomes of refractory and super-refractory status epilepticus, but it is known that as seizure activity persists, there is increased glutaminergic (dominant excitatory neurotransmitter in the CNS) activity which leads to intracellular calcium influx which eventually causes cerebral damage via various pathways.

  • Decrease time to benzodiazepine administration for patients in status epilepticus
  • Decrease length of hospital stay for patients in status epilepticus
  • Decrease morbidity and mortality of status epilepticus

Algorithm  Educational Module

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Attention: Critical Shortage of IV Lorazepam Nationwide

This is anticipated to be a long term shortage. In order to preserve the limited supplies, please consider using the following alternatives to Lorazepam IV: 

  • Diazepam IV (as listed as an alternative agent on the pathway)
  • Midazolam IV

Under development

  1. Glauser, T., Shinnar, S., Gloss, D., Alldredge, B., Arya, R., Bainbridge, J., . . . Treiman, D. M. (2016). Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Currents,16(1), 48-61. doi:10.5698/1535-7597-16.1.48
  2. Shorvon, S., & Ferlisi, M. (2011). The treatment of super-refractory status epilepticus: A critical review of available therapies and a clinical treatment protocol. Brain,134(10), 2802-2818. doi:10.1093/brain/awr215
  3. Shorvon, S., & Ferlisi, M. (2012). The outcome of therapies in refractory and super-refractory convulsive status epilepticus and recommendations for therapy. Brain,135(8), 2314-2328. doi:10.1093/brain/aws091
  4. Smith, D., Mcginnis, E., Walleigh, D., & Abend, N. (2016). Management of Status Epilepticus in Children. Journal of Clinical Medicine,5(4), 47. doi:10.3390/jcm5040047

The clinical pathways in the above links have been developed specifically for use at Connecticut Children’s and are made available publicly for informational and/or educational purposes only. The clinical pathways are not intended to be, nor are they, a substitute for individualized professional medical judgment, advice, diagnosis, or treatment. Although Connecticut Children’s makes all efforts to ensure the accuracy of the posted content, Connecticut Children’s makes no warranty of any kind as to the accuracy or completeness of the information or its fitness for use at any particular facility or in any individual case.